INTRODUCTION — Surgical sterilization is a safe, highly effective, permanent, and convenient form of contraception. The most common surgical sterilization procedure for women is called a tubal ligation or having the "tubes tied". The fallopian tubes are attached to the uterus and adjacent to the ovaries (show figure 1). The fallopian tubes are the site where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are separated or sealed shut, thus preventing the egg and sperm from meeting.
A tubal sterilization is usually performed by laparoscopic surgery, in which a flexible tube (laparoscope) is inserted through a small incision and used to view and operate inside a woman's abdomen. It can also be performed by a laparotomy, where an incision is made in the abdomen. This is most often performed in women who have recently given birth, during the postpartum period.
DECIDING TO HAVE A TUBAL LIGATION — Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or health care provider. In the United States, a woman's husband or partner is not required to give consent for the procedure, though both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy").
The physician should provide an explanation of the details of the procedure, including anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see "Outcomes" below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at anytime before the procedure.
Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by most insurance plans.
ALTERNATIVES — Alternatives to permanent female sterilization include male sterilization (vasectomy) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or hormone injections).
REGRET AFTER STERILIZATION — Regret after tubal sterilization occurs in 3 to 25 percent of women. However, only about 1 to 2 percent of all women who have undergone sterilization seek a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of sterilization.
For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their marriage or relationship should initially consider other birth control options. A healthcare provider may recommend that sterilization be delayed until a woman is sure of her decision, aware of the risks and benefits, and aware of the alternatives to permanent sterilization.
TIMING OF STERILIZATION — Sterilization can be performed at any time during a woman's menstrual cycle, though another form of birth control is recommended for one month before the procedure to reduce the risk of pregnancy (see below).
Sterilization can also be performed postpartum, after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the difficulty of the procedure and the risk of infection.
Contraception before and after sterilization — Some form of contraception (condom, diaphragm, birth control pill) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the tubal ligation. Performing the tubal ligation procedure immediately postpartum or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.
Although contraception is not necessary after the procedure, condoms should be used for protection against sexually transmitted diseases (eg, chlamydia, HIV) if the woman has multiple sex partners or a partner with other partners.
STERILIZATION PROCEDURES
Minilaparotomy — A minilaparotomy is commonly used postpartum; a small cut (one to three inches) is made in the abdomen, through which the procedure is performed on the fallopian tubes. General, regional, or local anesthesia can all be used for this procedure. In postpartum women, having the procedure does not lengthen the hospital stay.
There are three common surgical methods for the minilaparotomy that correspond to three different techniques of sealing the fallopian tubes: the Pomeroy technique (show figure 2-5), the Irving technique (show figure 6-9), or the Uchida method (show figure 10). Each has advantages and disadvantages.
One advantage of minilaparotomy is that a tissue specimen can be removed to prove the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [4].
Laparoscopic sterilization — Laparoscopic sterilization is the most common surgical method for interval (at a time unrelated to pregnancy) sterilization. In laparoscopic surgery, a small incision is cut near the belly button and in the lower abdomen and a flexible tube (laparoscope) is used to view the fallopian tubes and pelvis. The physician uses rings or clips to close the fallopian tubes or seals them shut using electrocoagulation (a procedure in which the fallopian tubes are cauterized) (show figure 11).
Severe heart or lung disease, a bleeding tendency, intraabdominal scarring, and obesity make laparoscopic procedures more dangerous and may prevent a woman from undergoing a laparoscopic sterilization.
Vaginal sterilization — The vaginal route for tubal sterilization is uncommon because it is more difficult to see the fallopian tubes than with the laparoscopic approach. In the vaginal sterilization technique, an incision is made through the vagina to reach the fallopian tubes, which are then cauterized, banded, or clipped.
Hysteroscopic sterilization — A minimally invasive hysteroscopic technique for tubal sterilization is also available. The Essure® permanent birth control procedure is a minimally invasive hysteroscopic technique for permanent tubal blockage whereby a tiny coil mechanism is inserted into the fallopian tube hysteroscopically under local anesthesia. Patients must use contraception until a procedure (called hysterosalpingogram) is performed three months after coil placement confirms tubal blockage. Some patients will require a second procedure if the tubes are not completely blocked.
OUTCOMES
Complications — The risk of surgical complications is approximately 1 in every 1000 procedures, but depend on the type of procedure. These complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia. Burns may occur if electrocautery is used. Blood clots and death are very rare.
Menstrual periods — There is no evidence that bleeding or uterine cramping is increased after tubal sterilization [5-7]. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more cycle irregularity than women who were not sterilized.
Sex — Tubal sterilization does not affect sexual desire or performance.
Pregnancy — Sterilization failure resulting in pregnancy is uncommon. In a study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, 143 women became pregnant (approximately 1 percent) [8,9] (show table 1A-1B) . The risk of pregnancy was highest among women sterilized at a young age (under age 30). When pregnancy occurs, it is more likely to be an ectopic pregnancy. (See "Patient information: Ectopic (tubal) pregnancy").
Other — Women who have undergone tubal sterilization have a slightly lower risk of developing ovarian cancer.
AFTER SURGERY — Patients may go home a few hours after an outpatient procedure, but someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such ibuprofen. Depending upon the type of procedure and anesthesia, patients may have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, or vaginal discharge/slight bleeding. Most patients should be able to return to a normal routine within a couple of days.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Planned Parenthood
(www.plannedparenthood.org)
Society of Obstetricians and Gynaecologists of Canada (SOGC)
(www.sogc.org/health)
Managing Contraception
(www.managingcontraception.com/cmanager/publish/choices.shtml)
[1-11]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Grubb, GS, Peterson, HB, Layde, PM, Rubin, GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.
2. Allyn, DP, Leton, DA, Westcott, NA, Hale, RW. Presterilization counseling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027.
3. Wilcox, LS, Chu, SY, Eaker, ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927.
4. American Coleege of Obstetricians and Gynecologists. Sterilization. ACOG technical Bulletin No. 222. ACOG, Washington, DC 1996.
5. DeStefano, F, Huezo, CM, Peterson, HB, et al. Menstrual changes after tubal sterilization. Obstet Gynecol 1983; 62:673.
6. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization with different occlusion techniques: a review of 10,004 cases. Am J Obstet Gynecol 1983; 145:684.
7. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization: a comparative study of electrocoagulation and the tubal ring in 1,025 cases. J Reprod Med 1982; 27:249.
8. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161.
9. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of ectopic pregnancy after tubal sterilization. N Engl J Med 1997; 336:762.
10. Miesfeld, RR, Giarratano, RC, Moyers, TG. Vaginal tubal ligation--is infection a significant risk? Am J Obstet Gynecol 1980; 137:183.
11. Lipscomb, GH, Stovall, TG, Summitt, RL, Ling, FW. Chromopertubation at laparoscopic tubal occlusion. Obstet Gynecol 1994; 83:725.
Sunday, October 14, 2007
Surgical sterilization of women
INTRODUCTION — Surgical sterilization is a safe, highly effective, permanent, and convenient form of contraception. The most common surgical sterilization procedure for women is called a tubal ligation or having the "tubes tied". The fallopian tubes are attached to the uterus and adjacent to the ovaries (show figure 1). The fallopian tubes are the site where the egg becomes fertilized by the male's sperm prior to traveling to the uterus. In tubal sterilization, the fallopian tubes are separated or sealed shut, thus preventing the egg and sperm from meeting.
A tubal sterilization is usually performed by laparoscopic surgery, in which a flexible tube (laparoscope) is inserted through a small incision and used to view and operate inside a woman's abdomen. It can also be performed by a laparotomy, where an incision is made in the abdomen. This is most often performed in women who have recently given birth, during the postpartum period.
DECIDING TO HAVE A TUBAL LIGATION — Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or health care provider. In the United States, a woman's husband or partner is not required to give consent for the procedure, though both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy").
The physician should provide an explanation of the details of the procedure, including anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see "Outcomes" below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at anytime before the procedure.
Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by most insurance plans.
ALTERNATIVES — Alternatives to permanent female sterilization include male sterilization (vasectomy) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or hormone injections).
REGRET AFTER STERILIZATION — Regret after tubal sterilization occurs in 3 to 25 percent of women. However, only about 1 to 2 percent of all women who have undergone sterilization seek a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of sterilization.
For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their marriage or relationship should initially consider other birth control options. A healthcare provider may recommend that sterilization be delayed until a woman is sure of her decision, aware of the risks and benefits, and aware of the alternatives to permanent sterilization.
TIMING OF STERILIZATION — Sterilization can be performed at any time during a woman's menstrual cycle, though another form of birth control is recommended for one month before the procedure to reduce the risk of pregnancy (see below).
Sterilization can also be performed postpartum, after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the difficulty of the procedure and the risk of infection.
Contraception before and after sterilization — Some form of contraception (condom, diaphragm, birth control pill) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the tubal ligation. Performing the tubal ligation procedure immediately postpartum or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.
Although contraception is not necessary after the procedure, condoms should be used for protection against sexually transmitted diseases (eg, chlamydia, HIV) if the woman has multiple sex partners or a partner with other partners.
STERILIZATION PROCEDURES
Minilaparotomy — A minilaparotomy is commonly used postpartum; a small cut (one to three inches) is made in the abdomen, through which the procedure is performed on the fallopian tubes. General, regional, or local anesthesia can all be used for this procedure. In postpartum women, having the procedure does not lengthen the hospital stay.
There are three common surgical methods for the minilaparotomy that correspond to three different techniques of sealing the fallopian tubes: the Pomeroy technique (show figure 2-5), the Irving technique (show figure 6-9), or the Uchida method (show figure 10). Each has advantages and disadvantages.
One advantage of minilaparotomy is that a tissue specimen can be removed to prove the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [4].
Laparoscopic sterilization — Laparoscopic sterilization is the most common surgical method for interval (at a time unrelated to pregnancy) sterilization. In laparoscopic surgery, a small incision is cut near the belly button and in the lower abdomen and a flexible tube (laparoscope) is used to view the fallopian tubes and pelvis. The physician uses rings or clips to close the fallopian tubes or seals them shut using electrocoagulation (a procedure in which the fallopian tubes are cauterized) (show figure 11).
Severe heart or lung disease, a bleeding tendency, intraabdominal scarring, and obesity make laparoscopic procedures more dangerous and may prevent a woman from undergoing a laparoscopic sterilization.
Vaginal sterilization — The vaginal route for tubal sterilization is uncommon because it is more difficult to see the fallopian tubes than with the laparoscopic approach. In the vaginal sterilization technique, an incision is made through the vagina to reach the fallopian tubes, which are then cauterized, banded, or clipped.
Hysteroscopic sterilization — A minimally invasive hysteroscopic technique for tubal sterilization is also available. The Essure® permanent birth control procedure is a minimally invasive hysteroscopic technique for permanent tubal blockage whereby a tiny coil mechanism is inserted into the fallopian tube hysteroscopically under local anesthesia. Patients must use contraception until a procedure (called hysterosalpingogram) is performed three months after coil placement confirms tubal blockage. Some patients will require a second procedure if the tubes are not completely blocked.
OUTCOMES
Complications — The risk of surgical complications is approximately 1 in every 1000 procedures, but depend on the type of procedure. These complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia. Burns may occur if electrocautery is used. Blood clots and death are very rare.
Menstrual periods — There is no evidence that bleeding or uterine cramping is increased after tubal sterilization [5-7]. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more cycle irregularity than women who were not sterilized.
Sex — Tubal sterilization does not affect sexual desire or performance.
Pregnancy — Sterilization failure resulting in pregnancy is uncommon. In a study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, 143 women became pregnant (approximately 1 percent) [8,9] (show table 1A-1B) . The risk of pregnancy was highest among women sterilized at a young age (under age 30). When pregnancy occurs, it is more likely to be an ectopic pregnancy. (See "Patient information: Ectopic (tubal) pregnancy").
Other — Women who have undergone tubal sterilization have a slightly lower risk of developing ovarian cancer.
AFTER SURGERY — Patients may go home a few hours after an outpatient procedure, but someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such ibuprofen. Depending upon the type of procedure and anesthesia, patients may have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, or vaginal discharge/slight bleeding. Most patients should be able to return to a normal routine within a couple of days.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Planned Parenthood
(www.plannedparenthood.org)
Society of Obstetricians and Gynaecologists of Canada (SOGC)
(www.sogc.org/health)
Managing Contraception
(www.managingcontraception.com/cmanager/publish/choices.shtml)
[1-11]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Grubb, GS, Peterson, HB, Layde, PM, Rubin, GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.
2. Allyn, DP, Leton, DA, Westcott, NA, Hale, RW. Presterilization counseling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027.
3. Wilcox, LS, Chu, SY, Eaker, ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927.
4. American Coleege of Obstetricians and Gynecologists. Sterilization. ACOG technical Bulletin No. 222. ACOG, Washington, DC 1996.
5. DeStefano, F, Huezo, CM, Peterson, HB, et al. Menstrual changes after tubal sterilization. Obstet Gynecol 1983; 62:673.
6. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization with different occlusion techniques: a review of 10,004 cases. Am J Obstet Gynecol 1983; 145:684.
7. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization: a comparative study of electrocoagulation and the tubal ring in 1,025 cases. J Reprod Med 1982; 27:249.
8. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161.
9. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of ectopic pregnancy after tubal sterilization. N Engl J Med 1997; 336:762.
10. Miesfeld, RR, Giarratano, RC, Moyers, TG. Vaginal tubal ligation--is infection a significant risk? Am J Obstet Gynecol 1980; 137:183.
11. Lipscomb, GH, Stovall, TG, Summitt, RL, Ling, FW. Chromopertubation at laparoscopic tubal occlusion. Obstet Gynecol 1994; 83:725.
A tubal sterilization is usually performed by laparoscopic surgery, in which a flexible tube (laparoscope) is inserted through a small incision and used to view and operate inside a woman's abdomen. It can also be performed by a laparotomy, where an incision is made in the abdomen. This is most often performed in women who have recently given birth, during the postpartum period.
DECIDING TO HAVE A TUBAL LIGATION — Sterilization is a major decision; it means that a woman and her partner do not want children at any time in the future. A woman's decision to undergo sterilization must be voluntary and not forced by her family, partner, or health care provider. In the United States, a woman's husband or partner is not required to give consent for the procedure, though both partners should have an understanding of the procedure as well as tubal sterilization's benefits, alternatives, and potential risks. The woman and her partner should review the risks and benefits of all methods of contraception, including male sterilization (vasectomy). (See "Patient information: Vasectomy").
The physician should provide an explanation of the details of the procedure, including anesthesia (general, spinal, local), and the possibility of pregnancy following the procedure (see "Outcomes" below), including the chance of ectopic pregnancy (when a pregnancy begins to grow outside the uterus, usually in the fallopian tubes). A woman may change her mind at anytime before the procedure.
Tubal sterilization should be considered permanent; reversing the procedure involves major surgery, is not always successful, and is rarely covered by most insurance plans.
ALTERNATIVES — Alternatives to permanent female sterilization include male sterilization (vasectomy) and reversible types of contraception (birth control pills/patch/vaginal ring, condoms, diaphragm, cervical cap, intrauterine device, or hormone injections).
REGRET AFTER STERILIZATION — Regret after tubal sterilization occurs in 3 to 25 percent of women. However, only about 1 to 2 percent of all women who have undergone sterilization seek a reversal of the procedure [1-3]. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of procedure, stress due to recent pregnancy complications, and young age (less than age 30) at the time of sterilization.
For these reasons, women who are younger than 30, have recently given birth and had significant complications (eg, premature birth, death of an infant), or who are having difficulty with their marriage or relationship should initially consider other birth control options. A healthcare provider may recommend that sterilization be delayed until a woman is sure of her decision, aware of the risks and benefits, and aware of the alternatives to permanent sterilization.
TIMING OF STERILIZATION — Sterilization can be performed at any time during a woman's menstrual cycle, though another form of birth control is recommended for one month before the procedure to reduce the risk of pregnancy (see below).
Sterilization can also be performed postpartum, after an abortion, or in conjunction with another surgical procedure (eg, gallbladder removal). Ideally, postpartum procedures are performed immediately after delivery or within 24 hours, but may be done up to seven days later. Further delay increases the difficulty of the procedure and the risk of infection.
Contraception before and after sterilization — Some form of contraception (condom, diaphragm, birth control pill) should be used before sterilization to decrease the risk of pregnancy. A woman can become pregnant if fertilization occurs just prior to the tubal ligation. Performing the tubal ligation procedure immediately postpartum or during a woman's menstrual period reduces the chance of becoming pregnant at the time of the procedure.
Although contraception is not necessary after the procedure, condoms should be used for protection against sexually transmitted diseases (eg, chlamydia, HIV) if the woman has multiple sex partners or a partner with other partners.
STERILIZATION PROCEDURES
Minilaparotomy — A minilaparotomy is commonly used postpartum; a small cut (one to three inches) is made in the abdomen, through which the procedure is performed on the fallopian tubes. General, regional, or local anesthesia can all be used for this procedure. In postpartum women, having the procedure does not lengthen the hospital stay.
There are three common surgical methods for the minilaparotomy that correspond to three different techniques of sealing the fallopian tubes: the Pomeroy technique (show figure 2-5), the Irving technique (show figure 6-9), or the Uchida method (show figure 10). Each has advantages and disadvantages.
One advantage of minilaparotomy is that a tissue specimen can be removed to prove the fallopian tubes have been completely cut. Disadvantages of minilaparotomy include a greater need for pain medication, slightly longer recovery time, and a larger surgical incision than with a laparoscopic procedure [4].
Laparoscopic sterilization — Laparoscopic sterilization is the most common surgical method for interval (at a time unrelated to pregnancy) sterilization. In laparoscopic surgery, a small incision is cut near the belly button and in the lower abdomen and a flexible tube (laparoscope) is used to view the fallopian tubes and pelvis. The physician uses rings or clips to close the fallopian tubes or seals them shut using electrocoagulation (a procedure in which the fallopian tubes are cauterized) (show figure 11).
Severe heart or lung disease, a bleeding tendency, intraabdominal scarring, and obesity make laparoscopic procedures more dangerous and may prevent a woman from undergoing a laparoscopic sterilization.
Vaginal sterilization — The vaginal route for tubal sterilization is uncommon because it is more difficult to see the fallopian tubes than with the laparoscopic approach. In the vaginal sterilization technique, an incision is made through the vagina to reach the fallopian tubes, which are then cauterized, banded, or clipped.
Hysteroscopic sterilization — A minimally invasive hysteroscopic technique for tubal sterilization is also available. The Essure® permanent birth control procedure is a minimally invasive hysteroscopic technique for permanent tubal blockage whereby a tiny coil mechanism is inserted into the fallopian tube hysteroscopically under local anesthesia. Patients must use contraception until a procedure (called hysterosalpingogram) is performed three months after coil placement confirms tubal blockage. Some patients will require a second procedure if the tubes are not completely blocked.
OUTCOMES
Complications — The risk of surgical complications is approximately 1 in every 1000 procedures, but depend on the type of procedure. These complications include infection, bowel or bladder injury, internal bleeding, and problems related to anesthesia. Burns may occur if electrocautery is used. Blood clots and death are very rare.
Menstrual periods — There is no evidence that bleeding or uterine cramping is increased after tubal sterilization [5-7]. In fact, women who undergo sterilization are more likely to have fewer days of bleeding during menstruation, a lower amount of blood loss, and less menstrual pain. However, sterilized women have described more cycle irregularity than women who were not sterilized.
Sex — Tubal sterilization does not affect sexual desire or performance.
Pregnancy — Sterilization failure resulting in pregnancy is uncommon. In a study of 10,685 women who underwent tubal sterilization and were followed for 8 to 14 years, 143 women became pregnant (approximately 1 percent) [8,9] (show table 1A-1B) . The risk of pregnancy was highest among women sterilized at a young age (under age 30). When pregnancy occurs, it is more likely to be an ectopic pregnancy. (See "Patient information: Ectopic (tubal) pregnancy").
Other — Women who have undergone tubal sterilization have a slightly lower risk of developing ovarian cancer.
AFTER SURGERY — Patients may go home a few hours after an outpatient procedure, but someone should be available to drive and help as needed. There will be some discomfort at the incision site and menstrual-type cramping; this can be treated with pain medication such ibuprofen. Depending upon the type of procedure and anesthesia, patients may have a sore throat (from a tube placed to help with breathing during general anesthesia), neck or shoulder pain, or vaginal discharge/slight bleeding. Most patients should be able to return to a normal routine within a couple of days.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
Planned Parenthood
(www.plannedparenthood.org)
Society of Obstetricians and Gynaecologists of Canada (SOGC)
(www.sogc.org/health)
Managing Contraception
(www.managingcontraception.com/cmanager/publish/choices.shtml)
[1-11]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Grubb, GS, Peterson, HB, Layde, PM, Rubin, GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.
2. Allyn, DP, Leton, DA, Westcott, NA, Hale, RW. Presterilization counseling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027.
3. Wilcox, LS, Chu, SY, Eaker, ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927.
4. American Coleege of Obstetricians and Gynecologists. Sterilization. ACOG technical Bulletin No. 222. ACOG, Washington, DC 1996.
5. DeStefano, F, Huezo, CM, Peterson, HB, et al. Menstrual changes after tubal sterilization. Obstet Gynecol 1983; 62:673.
6. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization with different occlusion techniques: a review of 10,004 cases. Am J Obstet Gynecol 1983; 145:684.
7. Bhiwandiwala, PP, Mumford, SD, Feldblum, PJ. Menstrual pattern changes following laparoscopic sterilization: a comparative study of electrocoagulation and the tubal ring in 1,025 cases. J Reprod Med 1982; 27:249.
8. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161.
9. Peterson, HB, Xia, Z, Hughes, JM, et al. The risk of ectopic pregnancy after tubal sterilization. N Engl J Med 1997; 336:762.
10. Miesfeld, RR, Giarratano, RC, Moyers, TG. Vaginal tubal ligation--is infection a significant risk? Am J Obstet Gynecol 1980; 137:183.
11. Lipscomb, GH, Stovall, TG, Summitt, RL, Ling, FW. Chromopertubation at laparoscopic tubal occlusion. Obstet Gynecol 1994; 83:725.
Long-term methods of birth control
INTRODUCTION — Several long-term or permanent methods of contraceptive are available for women who know that they do not wish to become pregnant in the near future (or ever). These methods are generally very effective, primarily because the woman is not required to do or remember anything on a regular basis.
This topic discusses long-term methods of birth control, including the intrauterine device, contraceptive implant, and sterilization. A discussion of hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
INTRAUTERINE DEVICE (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or infection.
Two IUDs are currently available: Copper-containing IUD (Paragard®, show picture 1), which prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (show table 2A-2B). Some women who use a copper-containing IUD have heavier and longer menstrual periods; this effect is reversed when the IUD is removed. Levonorgestrel-releasing IUD (Mirena®, show picture 2), which prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (show table 2A-2B). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.
Benefits — An IUD is an ideal method for a woman who does not plan to become pregnant for at least one year (or longer) or who wants a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want or cannot use estrogen.
IUDs have relatively few side effects, and are reversible, meaning that a woman who decides she wants to become pregnant can do so by having the IUD removed. IUDs do not affect a woman's ability to become pregnant after the IUD is removed.
Risks — Women who use an IUD should check its placement once per month, after the menstrual period, by finding the strings inside the vagina. There is a small risk of expulsion of the IUD during this time. If it is not possible to feel the strings, another method of contraception (eg, condoms) should be used until a healthcare provider confirms the IUD placement.
There is a small risk (1 in 1000 women) that the IUD will pass through the uterine wall during initial placement (called perforation). This may not be discovered until the first follow-up visit; if the IUD strings are not visible at this visit, a pelvic ultrasound or x-ray is needed to confirm that the IUD is in the uterus (rather than outside the uterus as a result of perforation). An IUD that is outside the uterus is usually removed during a day surgery procedure. A backup method of contraception is recommended after placement until the strings are felt or observed.
There is a small risk of uterine infection (9.6 in 1000 women) for up to 20 days after the insertion procedure; infection as a result of the IUD after this time is rare (1.4 in 1000 women). Testing for cervical or vaginal infections may be recommended before IUD insertion.
Precautions — Since the IUD does not protect against sexually transmitted infections, women at increased risk for STDs (including having multiple partners or a partner with multiple partners) or a history of recently (within three months) treated gonorrhea or chlamydia should consider using a different method of contraception. However, women in nonmonogamous relationships can decrease their risk of STDs by using condoms in addition to their IUD.
IUDs should not be used in women who have: Uterine or cervical abnormalities that severely distort the shape or size of the uterine cavity A current or recent pelvic infection or undiagnosed uterine bleeding
If a woman with an IUD becomes pregnant, an ultrasound is needed to confirm that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy").
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 3). It is effective for up to three years, and can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic.
It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. Over a three month period, the tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women (show picture 4). Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Westhoff, C, Davis, A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000; 73:913.
2. Peterson, HB, Jeng, G, Folger, SG, et al. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681.
3. Schwingl, PJ, Guess, HA. Safety and effectiveness of vasectomy. Fertil Steril 2000; 73:923.
4. Hubacher, D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98.
5. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.
This topic discusses long-term methods of birth control, including the intrauterine device, contraceptive implant, and sterilization. A discussion of hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
INTRAUTERINE DEVICE (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or infection.
Two IUDs are currently available: Copper-containing IUD (Paragard®, show picture 1), which prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (show table 2A-2B). Some women who use a copper-containing IUD have heavier and longer menstrual periods; this effect is reversed when the IUD is removed. Levonorgestrel-releasing IUD (Mirena®, show picture 2), which prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (show table 2A-2B). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.
Benefits — An IUD is an ideal method for a woman who does not plan to become pregnant for at least one year (or longer) or who wants a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want or cannot use estrogen.
IUDs have relatively few side effects, and are reversible, meaning that a woman who decides she wants to become pregnant can do so by having the IUD removed. IUDs do not affect a woman's ability to become pregnant after the IUD is removed.
Risks — Women who use an IUD should check its placement once per month, after the menstrual period, by finding the strings inside the vagina. There is a small risk of expulsion of the IUD during this time. If it is not possible to feel the strings, another method of contraception (eg, condoms) should be used until a healthcare provider confirms the IUD placement.
There is a small risk (1 in 1000 women) that the IUD will pass through the uterine wall during initial placement (called perforation). This may not be discovered until the first follow-up visit; if the IUD strings are not visible at this visit, a pelvic ultrasound or x-ray is needed to confirm that the IUD is in the uterus (rather than outside the uterus as a result of perforation). An IUD that is outside the uterus is usually removed during a day surgery procedure. A backup method of contraception is recommended after placement until the strings are felt or observed.
There is a small risk of uterine infection (9.6 in 1000 women) for up to 20 days after the insertion procedure; infection as a result of the IUD after this time is rare (1.4 in 1000 women). Testing for cervical or vaginal infections may be recommended before IUD insertion.
Precautions — Since the IUD does not protect against sexually transmitted infections, women at increased risk for STDs (including having multiple partners or a partner with multiple partners) or a history of recently (within three months) treated gonorrhea or chlamydia should consider using a different method of contraception. However, women in nonmonogamous relationships can decrease their risk of STDs by using condoms in addition to their IUD.
IUDs should not be used in women who have: Uterine or cervical abnormalities that severely distort the shape or size of the uterine cavity A current or recent pelvic infection or undiagnosed uterine bleeding
If a woman with an IUD becomes pregnant, an ultrasound is needed to confirm that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy").
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 3). It is effective for up to three years, and can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic.
It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. Over a three month period, the tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women (show picture 4). Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Westhoff, C, Davis, A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000; 73:913.
2. Peterson, HB, Jeng, G, Folger, SG, et al. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681.
3. Schwingl, PJ, Guess, HA. Safety and effectiveness of vasectomy. Fertil Steril 2000; 73:923.
4. Hubacher, D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98.
5. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.
Long-term methods of birth control
INTRODUCTION — Several long-term or permanent methods of contraceptive are available for women who know that they do not wish to become pregnant in the near future (or ever). These methods are generally very effective, primarily because the woman is not required to do or remember anything on a regular basis.
This topic discusses long-term methods of birth control, including the intrauterine device, contraceptive implant, and sterilization. A discussion of hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
INTRAUTERINE DEVICE (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or infection.
Two IUDs are currently available: Copper-containing IUD (Paragard®, show picture 1), which prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (show table 2A-2B). Some women who use a copper-containing IUD have heavier and longer menstrual periods; this effect is reversed when the IUD is removed. Levonorgestrel-releasing IUD (Mirena®, show picture 2), which prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (show table 2A-2B). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.
Benefits — An IUD is an ideal method for a woman who does not plan to become pregnant for at least one year (or longer) or who wants a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want or cannot use estrogen.
IUDs have relatively few side effects, and are reversible, meaning that a woman who decides she wants to become pregnant can do so by having the IUD removed. IUDs do not affect a woman's ability to become pregnant after the IUD is removed.
Risks — Women who use an IUD should check its placement once per month, after the menstrual period, by finding the strings inside the vagina. There is a small risk of expulsion of the IUD during this time. If it is not possible to feel the strings, another method of contraception (eg, condoms) should be used until a healthcare provider confirms the IUD placement.
There is a small risk (1 in 1000 women) that the IUD will pass through the uterine wall during initial placement (called perforation). This may not be discovered until the first follow-up visit; if the IUD strings are not visible at this visit, a pelvic ultrasound or x-ray is needed to confirm that the IUD is in the uterus (rather than outside the uterus as a result of perforation). An IUD that is outside the uterus is usually removed during a day surgery procedure. A backup method of contraception is recommended after placement until the strings are felt or observed.
There is a small risk of uterine infection (9.6 in 1000 women) for up to 20 days after the insertion procedure; infection as a result of the IUD after this time is rare (1.4 in 1000 women). Testing for cervical or vaginal infections may be recommended before IUD insertion.
Precautions — Since the IUD does not protect against sexually transmitted infections, women at increased risk for STDs (including having multiple partners or a partner with multiple partners) or a history of recently (within three months) treated gonorrhea or chlamydia should consider using a different method of contraception. However, women in nonmonogamous relationships can decrease their risk of STDs by using condoms in addition to their IUD.
IUDs should not be used in women who have: Uterine or cervical abnormalities that severely distort the shape or size of the uterine cavity A current or recent pelvic infection or undiagnosed uterine bleeding
If a woman with an IUD becomes pregnant, an ultrasound is needed to confirm that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy").
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 3). It is effective for up to three years, and can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic.
It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. Over a three month period, the tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women (show picture 4). Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Westhoff, C, Davis, A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000; 73:913.
2. Peterson, HB, Jeng, G, Folger, SG, et al. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681.
3. Schwingl, PJ, Guess, HA. Safety and effectiveness of vasectomy. Fertil Steril 2000; 73:923.
4. Hubacher, D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98.
5. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.
This topic discusses long-term methods of birth control, including the intrauterine device, contraceptive implant, and sterilization. A discussion of hormonal and barrier birth control methods are available separately. (See "Patient information: Hormonal methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
INTRAUTERINE DEVICE (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina. IUDs currently available in the United States do not increase a woman's risk of ectopic pregnancy, infertility, or infection.
Two IUDs are currently available: Copper-containing IUD (Paragard®, show picture 1), which prevents pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years; the pregnancy rate in women who use a copper-containing IUD is less than one percent in the first year of use (show table 2A-2B). Some women who use a copper-containing IUD have heavier and longer menstrual periods; this effect is reversed when the IUD is removed. Levonorgestrel-releasing IUD (Mirena®, show picture 2), which prevents pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). It also decreases menstrual bleeding by 40 to 90 percent and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy; the pregnancy rate in women who use a levonorgestrel-releasing IUD is less than one percent in the first year of use (show table 2A-2B). Some women completely stop having menstrual periods while using a levonorgestrel-releasing IUD; this is not harmful and does not require treatment. Menstrual periods will return when the IUD is removed.
Benefits — An IUD is an ideal method for a woman who does not plan to become pregnant for at least one year (or longer) or who wants a method that is highly effective and does not require daily or weekly attention. IUDs are also appropriate for women who do not want or cannot use estrogen.
IUDs have relatively few side effects, and are reversible, meaning that a woman who decides she wants to become pregnant can do so by having the IUD removed. IUDs do not affect a woman's ability to become pregnant after the IUD is removed.
Risks — Women who use an IUD should check its placement once per month, after the menstrual period, by finding the strings inside the vagina. There is a small risk of expulsion of the IUD during this time. If it is not possible to feel the strings, another method of contraception (eg, condoms) should be used until a healthcare provider confirms the IUD placement.
There is a small risk (1 in 1000 women) that the IUD will pass through the uterine wall during initial placement (called perforation). This may not be discovered until the first follow-up visit; if the IUD strings are not visible at this visit, a pelvic ultrasound or x-ray is needed to confirm that the IUD is in the uterus (rather than outside the uterus as a result of perforation). An IUD that is outside the uterus is usually removed during a day surgery procedure. A backup method of contraception is recommended after placement until the strings are felt or observed.
There is a small risk of uterine infection (9.6 in 1000 women) for up to 20 days after the insertion procedure; infection as a result of the IUD after this time is rare (1.4 in 1000 women). Testing for cervical or vaginal infections may be recommended before IUD insertion.
Precautions — Since the IUD does not protect against sexually transmitted infections, women at increased risk for STDs (including having multiple partners or a partner with multiple partners) or a history of recently (within three months) treated gonorrhea or chlamydia should consider using a different method of contraception. However, women in nonmonogamous relationships can decrease their risk of STDs by using condoms in addition to their IUD.
IUDs should not be used in women who have: Uterine or cervical abnormalities that severely distort the shape or size of the uterine cavity A current or recent pelvic infection or undiagnosed uterine bleeding
If a woman with an IUD becomes pregnant, an ultrasound is needed to confirm that the pregnancy is inside the uterus, rather than in the fallopian tube (called an ectopic pregnancy). The IUD should be removed when the pregnancy is discovered. (See "Patient information: Ectopic (tubal) pregnancy").
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. A healthcare provider inserts it under the skin in the upper inner arm (show picture 3). It is effective for up to three years, and can be removed sooner if pregnancy is desired. Insertion and removal can be done in an office or clinic.
It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. Over a three month period, the tissue around the coil grows into the coil, causing blockage of the fallopian tubes in most women (show picture 4). Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A backup method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; testing is usually done three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a healthcare provider's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Westhoff, C, Davis, A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000; 73:913.
2. Peterson, HB, Jeng, G, Folger, SG, et al. The risk of menstrual abnormalities after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 2000; 343:1681.
3. Schwingl, PJ, Guess, HA. Safety and effectiveness of vasectomy. Fertil Steril 2000; 73:923.
4. Hubacher, D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98.
5. Lethaby, AE, Cooke, I, Rees, M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2005; :CD002126.
Hormonal methods of birth control
INTRODUCTION — Hormonal methods of birth control contain estrogen and progestin, or progestin only, and are a safe and reliable way to prevent pregnancy for most women. There are several ways that the hormone(s) can be delivered, including by mouth in a daily pill, through the skin from a patch that is changed weekly, in an injection that is given once every three months, through an implant that is worn under the skin for up to three years, and from a ring worn in the vagina for three weeks.
This topic discusses hormonal methods of birth control, including birth control pills, injectable contraception, skin patches, vaginal rings, and contraceptive implants. A discussion of long-term and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 2). The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent over the first year, due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 3A-3B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Backup contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Complications — When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high. Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs. Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications. Therefore, oral contraceptives are now considered a reliable and safe option for most healthy, non-smoking women. Blood clots occur in approximately 4 women out of 10,000 using pills over a year's time. This compares to approximately one blood clot per 10,000 women who are not using pills.
The majority of studies suggest that taking (or having taken) the pill does not increase the risk of breast cancer.
Who should not take the pill? — Women who fall into the following categories should NOT take the pill because of an increased risk of complications: Aged 35 or over who smoke cigarettes (very high risk for cardiovascular complications) Are pregnant Have had blood clots or a stroke in the past, because these women are more likely to have blood clots while taking the pill Have a history of an estrogen-dependent tumor (eg, breast or uterine cancer) Have abnormal or unexplained menstrual bleeding (the cause of the bleeding should be investigated before starting the pill) Have active liver disease (the pill could worsen the liver disease)
Special concerns — Some women can take the pill, but need close monitoring: Women with high blood pressure can experience a further increase in blood pressure and should be monitored more frequently while on the pill. Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized. Women with migraine headaches associated with visual symptoms or other neurological symptoms should not use the pill. Women with diabetes mellitus who are on the pill may need a slightly higher dose of insulin or oral diabetes medication. Women with diabetes and vascular complications from diabetes should not use the pill.
Starting the pill — Ideally, the pill should be started on the first day of the period to provide maximum contraceptive effect in the first cycle; this provides protection from pregnancy immediately.
Many women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start). Some form of back-up contraception is needed for the first seven days after the Sunday start.
When to expect a period — The pill is taken on a 28-day cycle with 21 days of hormone pills followed by 7 days of placebo pills ("sugar pills"). It is not necessary to take the placebo pills, but some women find it easier to remember to start their next pill pack if they have taken the placebos. The period should occur during the fourth week of the pill pack, ie, the "placebo week." However, some women may experience breakthrough bleeding in the first few months. This almost always resolves without any intervention.
Continuous dosing — Some women prefer to take oral contraceptives continuously. This allows them to have fewer days of menstrual bleeding per year. This regimen is a particularly good treatment for women with painful periods or endometriosis, as well as those who want to avoid bleeding.
Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.
Seasonale® is an extended cycle oral contraceptive product in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is also an extended cycle oral contraceptive, although it contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawl symptoms.
Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten).
Shorter pill-free interval — Two pill formulations are available with 24 days of hormone pills (rather than 21) and only four days of placebo pills. It is hoped that pill failures and side effects will be minimized with this approach.
Progestin only pills — Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have worsened migraines or high blood pressure with combination contraceptive pills. Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A back up method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
Progestin only pills are taken on a 28-day cycle, and all 28 pills contain hormone. One pill should be taken every day at the same time, and there is no placebo pill week. Breakthrough bleeding or spotting can occur with progestin only pills.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available.
DMPA prevents ovulation and changes the cervical mucus, making the cervix impenetrable to sperm. If the first dose of DMPA is given during the first seven days of the menstrual period, it prevents pregnancy immediately. A woman who receives her first DMPA injection after the seventh day of her period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 3A-3B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection. DMPA is associated with weight gain in some women.
In women who use injectable progestins, there is no increased risk of cardiovascular complications or cancer. Use of DMPA is associated with decreased bone mineral density in current users. This effect is mostly reversed after DMPA is stopped. Studies have not shown an increased risk of bone fractures in women who have used DMPA in the past.
Because DMPA is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.
There are a number of women who prefer DMPA to the pill, including those who: Have difficulty remembering to take a pill every day Cannot use estrogen Also take seizure medications, which can be less effective with combination hormonal contraceptives.
Additional benefits of DMPA include a decreased risk of uterine cancer and pelvic inflammatory disease (PID).
TRANSDERMAL CONTRACEPTION (SKIN PATCH) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 3A-3B). However, the failure rate of the patch is greater (10 percent, as compared to 8 percent for the combination pill) for women who weigh more than 198 pounds.
Ortho Evra is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. Some healthcare providers are concerned that this will lead to an increased risk of blood clots; further study is needed to define this risk.
The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or hip (show picture 1). After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — Nuvaring® is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues (show picture 2A-2B). This prevents pregnancy, similar to an oral contraceptive (show table 3A-3B). It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time. The ring's position inside the vagina is not important.
Most women cannot feel the ring, and it is easy to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. It is inserted under the skin into the upper inner arm by a healthcare provider. It is effective for up to three years, but can be removed if pregnancy is desired sooner. Insertion and removal can be done in an office or clinic.
Implanon provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Petitti, DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003; 349:1443.
2. Baerwald, AR, Olatunbosun, OA, Pierson, RA. Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use. Contraception 2004; 70:371.
3. van Vliet, HA, Grimes, DA, Lopez, LM, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev 2006; 3:CD003553.
4. Edelman, A, Gallo, M, Jensen, J, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; :CD004695.
5. Gallo, MF, Grimes, DA, Schulz, KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2003; :CD003552.
This topic discusses hormonal methods of birth control, including birth control pills, injectable contraception, skin patches, vaginal rings, and contraceptive implants. A discussion of long-term and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 2). The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent over the first year, due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 3A-3B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Backup contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Complications — When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high. Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs. Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications. Therefore, oral contraceptives are now considered a reliable and safe option for most healthy, non-smoking women. Blood clots occur in approximately 4 women out of 10,000 using pills over a year's time. This compares to approximately one blood clot per 10,000 women who are not using pills.
The majority of studies suggest that taking (or having taken) the pill does not increase the risk of breast cancer.
Who should not take the pill? — Women who fall into the following categories should NOT take the pill because of an increased risk of complications: Aged 35 or over who smoke cigarettes (very high risk for cardiovascular complications) Are pregnant Have had blood clots or a stroke in the past, because these women are more likely to have blood clots while taking the pill Have a history of an estrogen-dependent tumor (eg, breast or uterine cancer) Have abnormal or unexplained menstrual bleeding (the cause of the bleeding should be investigated before starting the pill) Have active liver disease (the pill could worsen the liver disease)
Special concerns — Some women can take the pill, but need close monitoring: Women with high blood pressure can experience a further increase in blood pressure and should be monitored more frequently while on the pill. Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized. Women with migraine headaches associated with visual symptoms or other neurological symptoms should not use the pill. Women with diabetes mellitus who are on the pill may need a slightly higher dose of insulin or oral diabetes medication. Women with diabetes and vascular complications from diabetes should not use the pill.
Starting the pill — Ideally, the pill should be started on the first day of the period to provide maximum contraceptive effect in the first cycle; this provides protection from pregnancy immediately.
Many women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start). Some form of back-up contraception is needed for the first seven days after the Sunday start.
When to expect a period — The pill is taken on a 28-day cycle with 21 days of hormone pills followed by 7 days of placebo pills ("sugar pills"). It is not necessary to take the placebo pills, but some women find it easier to remember to start their next pill pack if they have taken the placebos. The period should occur during the fourth week of the pill pack, ie, the "placebo week." However, some women may experience breakthrough bleeding in the first few months. This almost always resolves without any intervention.
Continuous dosing — Some women prefer to take oral contraceptives continuously. This allows them to have fewer days of menstrual bleeding per year. This regimen is a particularly good treatment for women with painful periods or endometriosis, as well as those who want to avoid bleeding.
Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.
Seasonale® is an extended cycle oral contraceptive product in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is also an extended cycle oral contraceptive, although it contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawl symptoms.
Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten).
Shorter pill-free interval — Two pill formulations are available with 24 days of hormone pills (rather than 21) and only four days of placebo pills. It is hoped that pill failures and side effects will be minimized with this approach.
Progestin only pills — Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have worsened migraines or high blood pressure with combination contraceptive pills. Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A back up method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
Progestin only pills are taken on a 28-day cycle, and all 28 pills contain hormone. One pill should be taken every day at the same time, and there is no placebo pill week. Breakthrough bleeding or spotting can occur with progestin only pills.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available.
DMPA prevents ovulation and changes the cervical mucus, making the cervix impenetrable to sperm. If the first dose of DMPA is given during the first seven days of the menstrual period, it prevents pregnancy immediately. A woman who receives her first DMPA injection after the seventh day of her period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 3A-3B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection. DMPA is associated with weight gain in some women.
In women who use injectable progestins, there is no increased risk of cardiovascular complications or cancer. Use of DMPA is associated with decreased bone mineral density in current users. This effect is mostly reversed after DMPA is stopped. Studies have not shown an increased risk of bone fractures in women who have used DMPA in the past.
Because DMPA is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.
There are a number of women who prefer DMPA to the pill, including those who: Have difficulty remembering to take a pill every day Cannot use estrogen Also take seizure medications, which can be less effective with combination hormonal contraceptives.
Additional benefits of DMPA include a decreased risk of uterine cancer and pelvic inflammatory disease (PID).
TRANSDERMAL CONTRACEPTION (SKIN PATCH) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 3A-3B). However, the failure rate of the patch is greater (10 percent, as compared to 8 percent for the combination pill) for women who weigh more than 198 pounds.
Ortho Evra is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. Some healthcare providers are concerned that this will lead to an increased risk of blood clots; further study is needed to define this risk.
The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or hip (show picture 1). After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — Nuvaring® is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues (show picture 2A-2B). This prevents pregnancy, similar to an oral contraceptive (show table 3A-3B). It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time. The ring's position inside the vagina is not important.
Most women cannot feel the ring, and it is easy to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. It is inserted under the skin into the upper inner arm by a healthcare provider. It is effective for up to three years, but can be removed if pregnancy is desired sooner. Insertion and removal can be done in an office or clinic.
Implanon provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Petitti, DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003; 349:1443.
2. Baerwald, AR, Olatunbosun, OA, Pierson, RA. Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use. Contraception 2004; 70:371.
3. van Vliet, HA, Grimes, DA, Lopez, LM, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev 2006; 3:CD003553.
4. Edelman, A, Gallo, M, Jensen, J, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; :CD004695.
5. Gallo, MF, Grimes, DA, Schulz, KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2003; :CD003552.
Hormonal methods of birth control
INTRODUCTION — Hormonal methods of birth control contain estrogen and progestin, or progestin only, and are a safe and reliable way to prevent pregnancy for most women. There are several ways that the hormone(s) can be delivered, including by mouth in a daily pill, through the skin from a patch that is changed weekly, in an injection that is given once every three months, through an implant that is worn under the skin for up to three years, and from a ring worn in the vagina for three weeks.
This topic discusses hormonal methods of birth control, including birth control pills, injectable contraception, skin patches, vaginal rings, and contraceptive implants. A discussion of long-term and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 2). The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent over the first year, due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 3A-3B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Backup contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Complications — When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high. Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs. Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications. Therefore, oral contraceptives are now considered a reliable and safe option for most healthy, non-smoking women. Blood clots occur in approximately 4 women out of 10,000 using pills over a year's time. This compares to approximately one blood clot per 10,000 women who are not using pills.
The majority of studies suggest that taking (or having taken) the pill does not increase the risk of breast cancer.
Who should not take the pill? — Women who fall into the following categories should NOT take the pill because of an increased risk of complications: Aged 35 or over who smoke cigarettes (very high risk for cardiovascular complications) Are pregnant Have had blood clots or a stroke in the past, because these women are more likely to have blood clots while taking the pill Have a history of an estrogen-dependent tumor (eg, breast or uterine cancer) Have abnormal or unexplained menstrual bleeding (the cause of the bleeding should be investigated before starting the pill) Have active liver disease (the pill could worsen the liver disease)
Special concerns — Some women can take the pill, but need close monitoring: Women with high blood pressure can experience a further increase in blood pressure and should be monitored more frequently while on the pill. Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized. Women with migraine headaches associated with visual symptoms or other neurological symptoms should not use the pill. Women with diabetes mellitus who are on the pill may need a slightly higher dose of insulin or oral diabetes medication. Women with diabetes and vascular complications from diabetes should not use the pill.
Starting the pill — Ideally, the pill should be started on the first day of the period to provide maximum contraceptive effect in the first cycle; this provides protection from pregnancy immediately.
Many women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start). Some form of back-up contraception is needed for the first seven days after the Sunday start.
When to expect a period — The pill is taken on a 28-day cycle with 21 days of hormone pills followed by 7 days of placebo pills ("sugar pills"). It is not necessary to take the placebo pills, but some women find it easier to remember to start their next pill pack if they have taken the placebos. The period should occur during the fourth week of the pill pack, ie, the "placebo week." However, some women may experience breakthrough bleeding in the first few months. This almost always resolves without any intervention.
Continuous dosing — Some women prefer to take oral contraceptives continuously. This allows them to have fewer days of menstrual bleeding per year. This regimen is a particularly good treatment for women with painful periods or endometriosis, as well as those who want to avoid bleeding.
Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.
Seasonale® is an extended cycle oral contraceptive product in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is also an extended cycle oral contraceptive, although it contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawl symptoms.
Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten).
Shorter pill-free interval — Two pill formulations are available with 24 days of hormone pills (rather than 21) and only four days of placebo pills. It is hoped that pill failures and side effects will be minimized with this approach.
Progestin only pills — Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have worsened migraines or high blood pressure with combination contraceptive pills. Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A back up method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
Progestin only pills are taken on a 28-day cycle, and all 28 pills contain hormone. One pill should be taken every day at the same time, and there is no placebo pill week. Breakthrough bleeding or spotting can occur with progestin only pills.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available.
DMPA prevents ovulation and changes the cervical mucus, making the cervix impenetrable to sperm. If the first dose of DMPA is given during the first seven days of the menstrual period, it prevents pregnancy immediately. A woman who receives her first DMPA injection after the seventh day of her period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 3A-3B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection. DMPA is associated with weight gain in some women.
In women who use injectable progestins, there is no increased risk of cardiovascular complications or cancer. Use of DMPA is associated with decreased bone mineral density in current users. This effect is mostly reversed after DMPA is stopped. Studies have not shown an increased risk of bone fractures in women who have used DMPA in the past.
Because DMPA is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.
There are a number of women who prefer DMPA to the pill, including those who: Have difficulty remembering to take a pill every day Cannot use estrogen Also take seizure medications, which can be less effective with combination hormonal contraceptives.
Additional benefits of DMPA include a decreased risk of uterine cancer and pelvic inflammatory disease (PID).
TRANSDERMAL CONTRACEPTION (SKIN PATCH) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 3A-3B). However, the failure rate of the patch is greater (10 percent, as compared to 8 percent for the combination pill) for women who weigh more than 198 pounds.
Ortho Evra is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. Some healthcare providers are concerned that this will lead to an increased risk of blood clots; further study is needed to define this risk.
The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or hip (show picture 1). After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — Nuvaring® is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues (show picture 2A-2B). This prevents pregnancy, similar to an oral contraceptive (show table 3A-3B). It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time. The ring's position inside the vagina is not important.
Most women cannot feel the ring, and it is easy to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. It is inserted under the skin into the upper inner arm by a healthcare provider. It is effective for up to three years, but can be removed if pregnancy is desired sooner. Insertion and removal can be done in an office or clinic.
Implanon provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Petitti, DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003; 349:1443.
2. Baerwald, AR, Olatunbosun, OA, Pierson, RA. Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use. Contraception 2004; 70:371.
3. van Vliet, HA, Grimes, DA, Lopez, LM, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev 2006; 3:CD003553.
4. Edelman, A, Gallo, M, Jensen, J, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; :CD004695.
5. Gallo, MF, Grimes, DA, Schulz, KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2003; :CD003552.
This topic discusses hormonal methods of birth control, including birth control pills, injectable contraception, skin patches, vaginal rings, and contraceptive implants. A discussion of long-term and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control"). An overview of all birth control methods is also available. (See "Patient information: Contraception").
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and which does no cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and decide which method she prefers. A list of questions that are useful for defining a person's preferences are provided in the table (show table 1).
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 2). The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is 0.1 percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent over the first year, due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 3A-3B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Backup contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Complications — When the pill was first introduced in the 1960s, the doses of both estrogen and progestin were quite high. Because of this, cardiovascular complications occurred, such as high blood pressure, heart attacks, strokes, and blood clots in the legs and lungs. Reduced doses of progestin and estrogen in the currently available oral contraceptives have decreased these complications. Therefore, oral contraceptives are now considered a reliable and safe option for most healthy, non-smoking women. Blood clots occur in approximately 4 women out of 10,000 using pills over a year's time. This compares to approximately one blood clot per 10,000 women who are not using pills.
The majority of studies suggest that taking (or having taken) the pill does not increase the risk of breast cancer.
Who should not take the pill? — Women who fall into the following categories should NOT take the pill because of an increased risk of complications: Aged 35 or over who smoke cigarettes (very high risk for cardiovascular complications) Are pregnant Have had blood clots or a stroke in the past, because these women are more likely to have blood clots while taking the pill Have a history of an estrogen-dependent tumor (eg, breast or uterine cancer) Have abnormal or unexplained menstrual bleeding (the cause of the bleeding should be investigated before starting the pill) Have active liver disease (the pill could worsen the liver disease)
Special concerns — Some women can take the pill, but need close monitoring: Women with high blood pressure can experience a further increase in blood pressure and should be monitored more frequently while on the pill. Women who take certain medication for seizures (epilepsy) and take the pill have a slightly higher risk of pill failure (pregnancy) because the seizure medicines change the way the pill is metabolized. Women with migraine headaches associated with visual symptoms or other neurological symptoms should not use the pill. Women with diabetes mellitus who are on the pill may need a slightly higher dose of insulin or oral diabetes medication. Women with diabetes and vascular complications from diabetes should not use the pill.
Starting the pill — Ideally, the pill should be started on the first day of the period to provide maximum contraceptive effect in the first cycle; this provides protection from pregnancy immediately.
Many women start their pill on the first Sunday after the period starts (because most pill packs are arranged for a Sunday start). Some form of back-up contraception is needed for the first seven days after the Sunday start.
When to expect a period — The pill is taken on a 28-day cycle with 21 days of hormone pills followed by 7 days of placebo pills ("sugar pills"). It is not necessary to take the placebo pills, but some women find it easier to remember to start their next pill pack if they have taken the placebos. The period should occur during the fourth week of the pill pack, ie, the "placebo week." However, some women may experience breakthrough bleeding in the first few months. This almost always resolves without any intervention.
Continuous dosing — Some women prefer to take oral contraceptives continuously. This allows them to have fewer days of menstrual bleeding per year. This regimen is a particularly good treatment for women with painful periods or endometriosis, as well as those who want to avoid bleeding.
Traditional birth control pill packs can be used in continuous dosing. In this regimen, the woman takes the first three weeks of a pill pack, then immediately starts a new pack (without a break); the last week of (placebo) pills is not used. This can be continued for as long as desired.
Seasonale® is an extended cycle oral contraceptive product in which an active pill is taken every day for 12 weeks, followed by seven days of inactive (placebo) pills. Seasonique® is also an extended cycle oral contraceptive, although it contains seven days of a low dose estrogen pills instead of the placebo pills; this is intended to reduce breakthrough bleeding and estrogen withdrawl symptoms.
Taking an oral contraceptive for an extended time results in fewer periods per year, although many women experience breakthrough bleeding when starting this regimen. Breakthrough bleeding is inconvenient, but does not indicate an increased risk of pill failure (unless pills are forgotten).
Shorter pill-free interval — Two pill formulations are available with 24 days of hormone pills (rather than 21) and only four days of placebo pills. It is hoped that pill failures and side effects will be minimized with this approach.
Progestin only pills — Some pills contain only progestin (called the mini pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have worsened migraines or high blood pressure with combination contraceptive pills. Progestin only pills are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A back up method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
Progestin only pills are taken on a 28-day cycle, and all 28 pills contain hormone. One pill should be taken every day at the same time, and there is no placebo pill week. Breakthrough bleeding or spotting can occur with progestin only pills.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available.
DMPA prevents ovulation and changes the cervical mucus, making the cervix impenetrable to sperm. If the first dose of DMPA is given during the first seven days of the menstrual period, it prevents pregnancy immediately. A woman who receives her first DMPA injection after the seventh day of her period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 3A-3B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during the first few months of use. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection. DMPA is associated with weight gain in some women.
In women who use injectable progestins, there is no increased risk of cardiovascular complications or cancer. Use of DMPA is associated with decreased bone mineral density in current users. This effect is mostly reversed after DMPA is stopped. Studies have not shown an increased risk of bone fractures in women who have used DMPA in the past.
Because DMPA is long-acting, it may not be ideal for women who wish to become pregnant shortly after stopping the medication. Although most women are able to conceive within 10 months, fertility may not return for up to 18 months after the last injection.
There are a number of women who prefer DMPA to the pill, including those who: Have difficulty remembering to take a pill every day Cannot use estrogen Also take seizure medications, which can be less effective with combination hormonal contraceptives.
Additional benefits of DMPA include a decreased risk of uterine cancer and pelvic inflammatory disease (PID).
TRANSDERMAL CONTRACEPTION (SKIN PATCH) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 3A-3B). However, the failure rate of the patch is greater (10 percent, as compared to 8 percent for the combination pill) for women who weigh more than 198 pounds.
Ortho Evra is the only skin patch contraceptive available in the United States. Effectiveness is similar to that of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. Some healthcare providers are concerned that this will lead to an increased risk of blood clots; further study is needed to define this risk.
The patch is worn for one week on the upper arm, shoulder, upper back, abdomen, or hip (show picture 1). After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — Nuvaring® is a flexible plastic vaginal ring that contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues (show picture 2A-2B). This prevents pregnancy, similar to an oral contraceptive (show table 3A-3B). It is worn in the vagina for three weeks, followed by one week when no ring is used; a menstrual period occurs during this time. The ring's position inside the vagina is not important.
Most women cannot feel the ring, and it is easy to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon®, has been approved for use in the US and elsewhere. It is inserted under the skin into the upper inner arm by a healthcare provider. It is effective for up to three years, but can be removed if pregnancy is desired sooner. Insertion and removal can be done in an office or clinic.
Implanon provides three years of protection from pregnancy as progestin is slowly absorbed into the surrounding tissues. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
[1-5]
Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Petitti, DB. Clinical practice. Combination estrogen-progestin oral contraceptives. N Engl J Med 2003; 349:1443.
2. Baerwald, AR, Olatunbosun, OA, Pierson, RA. Ovarian follicular development is initiated during the hormone-free interval of oral contraceptive use. Contraception 2004; 70:371.
3. van Vliet, HA, Grimes, DA, Lopez, LM, et al. Triphasic versus monophasic oral contraceptives for contraception. Cochrane Database Syst Rev 2006; 3:CD003553.
4. Edelman, A, Gallo, M, Jensen, J, et al. Continuous or extended cycle vs. cyclic use of combined oral contraceptives for contraception. Cochrane Database Syst Rev 2005; :CD004695.
5. Gallo, MF, Grimes, DA, Schulz, KF. Skin patch and vaginal ring versus combined oral contraceptives for contraception. Cochrane Database Syst Rev 2003; :CD003552.
Contraception
INTRODUCTION — Contraception or birth control is the use of a medication, device, or method to prevent pregnancy. Such devices or techniques, known as contraceptives, work to: Prevent ovulation, the release of eggs from a woman's ovary Prevent sperm from getting into the uterus and fallopian tubes (where fertilization of the egg normally occurs) Prevent implantation of the embryo (fertilized egg) into the uterine lining (endometrium)
Most women of reproductive age in the United States use some form of contraception. However, unintended pregnancy is still a common problem in this country. Almost one-half of pregnancies are estimated to be unintended.
This topic is an overview of all methods of birth control. More detailed discussions of hormonal, long-term, and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control" and see "Patient information: Hormonal methods of birth control").
EFFECTIVENESS OF CONTRACEPTION — Most contraceptive methods are quite effective if used properly. However, the actual effectiveness of a method can differ from "perfect use" effectiveness (show table 1A-1B). Contraceptives fail for a number of reasons, including improper use, failure to follow treatment recommendations, or failure of the medication, device, or method itself.
Certain contraceptives, such as intrauterine devices (IUDs) and injectable contraceptives, have a low risk of failure (pregnancy). This is because compliance (using the method correctly or taking the medication on a regular basis) is not a major factor. (See "Patient information: Long-term methods of birth control").
Oral contraceptives (birth control pills) have a low pregnancy rate if they are taken properly (ie, pills are taken every day). However, the actual pregnancy rate is much higher because many women forget to take the pill every day. (See "Patient information: Hormonal methods of birth control").
Other contraceptive methods such as the condom, diaphragm/cervical cap, and spermicides can be very effective if used properly. However, these methods are also associated with higher "actual" pregnancy rates because of incorrect or inconsistent use. (See "Patient information: Barrier methods of birth control").
Overall, contraceptive methods that are designed for use at or near the occurrence of intercourse (eg, the condom, diaphragm) are generally less effective than contraceptive methods that are unrelated to the occurrence of sexual activity (eg, intrauterine device, oral contraceptives).
Women who are at risk of pregnancy and are using birth control should also have a supply of emergency contraceptive pills on hand (See "Emergency contraception" below).
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and does not cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and then choose the most effective method that she feels she will be able to use consistently and correctly. A list of questions that are useful for defining a person's preferences are provided in the table (show table 2).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, but pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (the United States Federal policy is that a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 3 and show table 4). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device (IUD) is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age (a government issued ID) is required. Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 5). A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is less than one percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 1A-1B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Back-up contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain, as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Progestin only pills — Some pills contain only progestin (called the mini-pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have aggravation of migraines or high blood pressure with combination contraceptive pills. Progestin only pills (or mini-pills) are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A backup method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available. A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
DMPA prevents ovulation and alters the cervical mucus, making the cervix impenetrable to sperm. DMPA also thins the uterine lining. Women who receive their first DMPA injection more than seven days after their menstrual period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 1A-1B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during early therapy. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection.
A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
TRANSDERMAL CONTRACEPTION (SKIN PATCHES) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 1A-1B). Ortho Evra is the only transdermal contraceptive available in the United States. Risks and effectiveness are similar to those of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. There is concern that this could increase the risk of blood clots, although this has not been proven.
The patch is worn for one week on the upper arm, shoulder, upper back, or hip. After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — A flexible plastic vaginal ring (Nuvaring®) contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues. This prevents pregnancy, similar to an oral contraceptive. It is worn inside the vagina for three weeks, followed by one week when no ring is used; the menstrual period occurs during this time. The ring is not noticeable, and it is easy for most women to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon, is available in the US and elsewhere. It provides three years of protection from pregnancy as progestin is slowly absorbed into the body. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
BARRIER METHODS — This type of contraceptive physically blocks or otherwise prevents sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. A full discussion of barrier methods of birth control is available separately. (See "Patient information: Barrier methods of birth control").
Male condom — The male condom is a thin, flexible sheath, or cover, placed over the penis to prevent semen from entering the vagina during sexual intercourse. To help ensure optimal effectiveness and protection, men who use condoms must carefully follow instructions for their use. Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone. However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide. Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom.
Many women who choose a contraceptive other than condoms also choose to use condoms to decrease their risk of acquiring a sexually transmitted disease.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane, and is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The woman should check to make sure the condom is not twisted.
Diaphragm/cervical cap — The diaphragm and cervical cap fit over the cervix, preventing sperm from entering the uterus. These devices are available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes, and require fitting by a clinician. These devices must be used with a spermicide and left in place for six to eight hours after sexual intercourse. The diaphragm must be removed after this period. However, the cervical cap can remain in place for up to 24 hours.
Spermicide — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
INTRAUTERINE DEVICES (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina, enabling a woman to check that the device remains in place.
The currently available IUDs are safe and effective. These devices include: Copper-containing IUDs prevent pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years. Levonorgestrel-releasing IUDs, prevent pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). They also decrease menstrual bleeding by 40 to 90 percent and decrease pain associated with periods. They can be left in place for up to five years, and are highly effective in preventing pregnancy. Some women stop having menstrual periods entirely; this effect is reversed when the IUD is removed.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedures for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. The coil blocks the fallopian tubes three months after placement in most women. Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A back up method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; this is usually performed three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a doctor's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
OTHER METHODS — Some women and their partners cannot or choose not to use the contraceptive methods mentioned above due to religious or cultural reasons. Alternate birth control options include periodic abstinence and withdrawal.
Periodic abstinence — Periodic abstinence involves trying to predict the time of the month when a woman is most fertile, and abstaining from sexual intercourse during that time. Different methods may be used to help determine the fertile period:
Rhythm or calendar method — This uses the date of the last menstrual period to determine a woman's most fertile period. The first day of the fertile period is calculated by subtracting 18 days from the shortest menstrual cycle. The menstrual cycle is defined as the number of days from the start of one period to the start of the next period. The last day of the fertile period is calculated by subtracting 11 days from the length of the longest cycle. For example, if a woman's menstrual cycle varies from 28 to 30 days, she should refrain from intercourse from days 10 to 19 of each cycle. Day 1 is the first day of bleeding. This method is not appropriate for a woman who has irregular menstrual cycles and women who have recently delivered a baby or who are breastfeeding.
Basal body temperature — This method is based upon changes in body temperature that occur during a woman's cycle. A woman takes her temperature before getting out of bed in the morning; this is called the basal body temperature. Basal temperature rise slightly (about 0.5ยบ F) after release of the egg. Intercourse should be avoided between the start of the menstrual cycle (day one) until three days after the temperature rises. For most women, this requires abstinence for two weeks. This method is not recommended for women who breastfeeding or nearing menopause.
Cervical mucus — This method uses the color, amount, and consistency of a woman's cervical mucus, which change through a woman's cycle. During ovulation, the mucus is typically watery and in larger amounts than at other times. Intercourse should be avoided when watery cervical mucus first appears until three to four days after the heaviest day of mucus production.
When used perfectly, basal body temperature plus cervical mucus monitoring methods are more effective than the calendar or rhythm method. The estimated failure rates are 3 and 9 percent, respectively (show table 1A-1B). However, failure rates may be as high as 86 percent (with a 28 percent risk of pregnancy per cycle) if used incorrectly.
Withdrawal — Also known as coitus interruptus, the withdrawal method requires the man to withdraw his penis from the vagina before ejaculation. Pregnancy may occur if withdrawal occurs too late or if sperm is released before orgasm (in preejaculatory fluid). With this method, contraceptive failure rates may be as high as 18 to 20 percent (show table 1A-1B).
Breastfeeding — Breastfeeding after childbirth has limited effectiveness in preventing pregnancy due to a delay in the return of ovulation. Approximately 88 percent of women who breastfeed exclusively (meaning that no formula is given and the baby is fed on demand) do not ovulate for six months. If the woman does not have a menstrual period, she is more than 98 percent protected from pregnancy for the first six months (show table 1A-1B). Women who use supplemental feeding (formula) and those who menstruate are more likely to ovulate.
It is probably safest to resume a contraceptive in the third month following childbirth for those who breastfeed exclusively and in the third week postpartum for those who do not breastfeed or do so infrequently. A healthcare provider can help to determine the best timing and form of contraception following childbirth.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Abma, JC, Chandra, A, Mosher, WD, et al. and the National Center for Health Statistics. Fertility, family planning, and women's health: New data from the 1995 Survey of Family Growth. Vital Statistics; Series 23 No.19.
2. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
3. Steiner, MJ. Contraceptive effectiveness: what should the counseling message be?. JAMA 1999; 282:1405.
4. Trussell, J, Vaughan, B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:64.
Most women of reproductive age in the United States use some form of contraception. However, unintended pregnancy is still a common problem in this country. Almost one-half of pregnancies are estimated to be unintended.
This topic is an overview of all methods of birth control. More detailed discussions of hormonal, long-term, and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and see "Patient information: Barrier methods of birth control" and see "Patient information: Hormonal methods of birth control").
EFFECTIVENESS OF CONTRACEPTION — Most contraceptive methods are quite effective if used properly. However, the actual effectiveness of a method can differ from "perfect use" effectiveness (show table 1A-1B). Contraceptives fail for a number of reasons, including improper use, failure to follow treatment recommendations, or failure of the medication, device, or method itself.
Certain contraceptives, such as intrauterine devices (IUDs) and injectable contraceptives, have a low risk of failure (pregnancy). This is because compliance (using the method correctly or taking the medication on a regular basis) is not a major factor. (See "Patient information: Long-term methods of birth control").
Oral contraceptives (birth control pills) have a low pregnancy rate if they are taken properly (ie, pills are taken every day). However, the actual pregnancy rate is much higher because many women forget to take the pill every day. (See "Patient information: Hormonal methods of birth control").
Other contraceptive methods such as the condom, diaphragm/cervical cap, and spermicides can be very effective if used properly. However, these methods are also associated with higher "actual" pregnancy rates because of incorrect or inconsistent use. (See "Patient information: Barrier methods of birth control").
Overall, contraceptive methods that are designed for use at or near the occurrence of intercourse (eg, the condom, diaphragm) are generally less effective than contraceptive methods that are unrelated to the occurrence of sexual activity (eg, intrauterine device, oral contraceptives).
Women who are at risk of pregnancy and are using birth control should also have a supply of emergency contraceptive pills on hand (See "Emergency contraception" below).
CHOOSING A METHOD — It can be difficult to decide which birth control method is best due to the variety of options available. The best method is one that will be used consistently, is acceptable to the woman and her partner, and does not cause bothersome side effects. Other factors to consider include: Efficacy Convenience Duration of action Reversibility and time to return of fertility Effect on uterine bleeding Frequency of side effects and adverse events Affordability Protection against sexually transmitted diseases
No method of contraception is perfect. Each woman must balance the advantages of each method against the disadvantages and then choose the most effective method that she feels she will be able to use consistently and correctly. A list of questions that are useful for defining a person's preferences are provided in the table (show table 2).
EMERGENCY CONTRACEPTION — Emergency contraception (EC, also known as postcoital contraception or the morning-after pill) refers to the use of drugs to prevent pregnancy in women who have had recent unprotected intercourse (including sexual assault), or who have had a failure of another method of contraception (eg, broken condom). As many as 30 percent of women will become pregnant after a single unprotected act of sex that occurs near the time of ovulation. Use of EC significantly reduces the chance of pregnancy, but pregnancy may still occur.
Experts are uncertain about how EC prevents pregnancy. Since these drugs are taken within hours of intercourse and implantation does not occur until approximately five to seven days after ovulation, use of EC does not interrupt pregnancy (the United States Federal policy is that a woman is considered pregnant once a conceptus has implanted; however, some consider pregnancy to begin at conception).
Several options are available for EC (show table 3 and show table 4). Plan B is a pill pack that contains two 0.75 mg tablets of levonorgestrel, both of which should be taken as soon as possible after unprotected sex. It is also acceptable to take one pill as soon as possible, followed by the second pill 12 hours later (this is the instruction given by the manufacturer). The cost is approximately $40. The Plan B regimen is more effective and better tolerated than regimens using oral contraceptive pills that contain estrogen (eg, Ovral two tablets twelve hours apart or Lo/Ovral four tablets 12 hours apart).
Nausea and vomiting are the major side effects of the estrogen-containing regimen. A medication to reduce nausea and vomiting can be taken one hour before the first dose. Nausea and vomiting is less common with the levonorgestrel method. However, if levonorgestrel is vomited within one hour of taking it, a medication to prevent nausea can be taken, followed by a repeat of the EC dose.
EC is most effective when taken as soon as possible after intercourse. However, studies have shown that it is somewhat effective for up to 120 hours (five days) after intercourse, and may be started up to that time if necessary. After five days, insertion of a copper intrauterine device (IUD) is considered the best way to prevent pregnancy. (See "Patient information: Long-term methods of birth control").
A risk of pregnancy still exists if the woman has unprotected intercourse after EC pills have been taken. Therefore, another method of contraception (eg, condoms) should be used for the rest of the cycle. A second dose of EC may be used if a second episode of unprotected intercourse occurs anytime after the first dose.
A woman who is sexually active and does not want to become pregnant can consider purchasing EC before it is needed. This would eliminate any delay in taking the first dose. In the United States, EC is approved as an over the counter medication for individuals (men or women) age 18 and older; proof of age (a government issued ID) is required. Younger patients still require a prescription. Plan B is only available at sites with a licensed pharmacist.
ORAL CONTRACEPTIVES — Most oral contraceptives, also referred to as "the pill," contain a combination of female hormones, estrogen and progestin (a progesterone-like medication). A list of available pills is shown in the table (show table 5). A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
The combination pill reduces the risk of pregnancy by: Preventing ovulation Keeping the mucus in the cervix thick and impenetrable to sperm Keeping the lining of the uterus thin
Other non-contraceptive benefits of the pill include a reduction in: Menstrual cramps or pain (dysmenorrhea) Ovarian cancer Cancer of the endometrium (uterine lining) Acne Iron-deficiency anemia (a low blood count due to low iron levels)
Efficacy — When taken properly, OCs are a very effective form of contraception. Although the failure rate is less than one percent when pills are taken perfectly (same time every day, no missed pills), the actual failure rate is 8 percent due primarily to missed pills or failure to restart the pill after the seven-day pill-free interval (show table 1A-1B).
Missed pills are a common cause of contraceptive failure. In general, an active pill should be taken as soon as possible after a pill has been missed. Back-up contraception should be used for seven days if more than two pills are missed.
Side effects — Side effects of the pill include: Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months. Breakthrough bleeding or spotting. This is particularly common during the first few months of taking oral contraceptives. Forgetting a pill can also cause breakthrough bleeding.
Women taking the pill should notify their healthcare provider if they experience abdominal pain, chest pain, severe headaches, eye problems, or severe leg pain, as these could be symptoms of several serious conditions including heart attack, blood clot, stroke, liver, and gallbladder disease.
Progestin only pills — Some pills contain only progestin (called the mini-pill), which is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have aggravation of migraines or high blood pressure with combination contraceptive pills. Progestin only pills (or mini-pills) are as effective as combination pills when taken at the same time every day, but there is a slightly higher failure rate of the mini pill if the woman is more than three hours late in taking it. A backup method of birth control should be used for seven days if a pill is forgotten or taken more that three hours late.
INJECTABLE CONTRACEPTION — The only injectable contraceptive currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A preparation that is given subcutaneously (under the skin) is also available. A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
DMPA prevents ovulation and alters the cervical mucus, making the cervix impenetrable to sperm. DMPA also thins the uterine lining. Women who receive their first DMPA injection more than seven days after their menstrual period should use a second form of contraception (eg, condoms) for seven days. DMPA is very effective, with a failure (pregnancy) rate of less than one percent (show table 1A-1B).
Side effects — The most common side effects of DMPA are irregular or prolonged bleeding and spotting, particularly during early therapy. Up to 50 percent of women completely stop having menstrual periods (amenorrhea) after one year of DMPA use. Menses generally return within six months of the last DMPA injection.
A full discussion of hormonal birth control methods is available separately. (See "Patient information: Hormonal methods of birth control").
TRANSDERMAL CONTRACEPTION (SKIN PATCHES) — Transdermal contraceptive patches contain estrogen and progestin, similar to oral contraceptives. The patch is as effective as oral contraceptives, and may be preferred by some women because it does not require daily dosing (show table 1A-1B). Ortho Evra is the only transdermal contraceptive available in the United States. Risks and effectiveness are similar to those of oral contraceptive pills. However, the patch appears to deliver a higher overall amount of estrogen than the pill. There is concern that this could increase the risk of blood clots, although this has not been proven.
The patch is worn for one week on the upper arm, shoulder, upper back, or hip. After one week, the old patch is removed and a new patch is applied; this is done for three weeks. During the fourth week, no patch is worn; the menstrual period occurs during this week.
VAGINAL RING — A flexible plastic vaginal ring (Nuvaring®) contains estrogen and a progestin, which is slowly absorbed through the vaginal tissues. This prevents pregnancy, similar to an oral contraceptive. It is worn inside the vagina for three weeks, followed by one week when no ring is used; the menstrual period occurs during this time. The ring is not noticeable, and it is easy for most women to insert and remove. It may be removed for up to three hours if desired, such as during intercourse, although it is not usually felt by the sexual partner. Risks and side effects are similar to those of oral contraceptives.
CONTRACEPTIVE IMPLANT — A single-rod progestin implant, Implanon, is available in the US and elsewhere. It provides three years of protection from pregnancy as progestin is slowly absorbed into the body. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Fertility returns rapidly after removal of the rod.
BARRIER METHODS — This type of contraceptive physically blocks or otherwise prevents sperm from entering the uterus and reaching the egg for fertilization. Barrier contraceptives include the condom, diaphragm, and cervical cap. A full discussion of barrier methods of birth control is available separately. (See "Patient information: Barrier methods of birth control").
Male condom — The male condom is a thin, flexible sheath, or cover, placed over the penis to prevent semen from entering the vagina during sexual intercourse. To help ensure optimal effectiveness and protection, men who use condoms must carefully follow instructions for their use. Condoms are most effective when used with a vaginally-applied spermicide (see "Spermicide" below); use of the male condom and a vaginal spermicide is as effective as a hormonal method of contraception, and is more effective to prevent pregnancy than a condom alone. However, spermicidal condoms (those that are packaged with spermicide applied to the condom) are no more effective and expire faster than condoms without spermicide. Oil-based lubricants (eg, suntan oil, petroleum jelly, whipped cream) should not be used with latex condoms because this can cause breakage of the condom.
Many women who choose a contraceptive other than condoms also choose to use condoms to decrease their risk of acquiring a sexually transmitted disease.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane, and is prelubricated with a silicone-based lubricant. There is a soft, flexible ring at each end. The edges of the ring at the closed end of the sheath are squeezed together and then inserted as far as possible into the vagina; upon release, the ring will open to hold the condom in place. The ring at the open end of the sheath remains outside the vulva, resting against the labia. The woman should check to make sure the condom is not twisted.
Diaphragm/cervical cap — The diaphragm and cervical cap fit over the cervix, preventing sperm from entering the uterus. These devices are available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes, and require fitting by a clinician. These devices must be used with a spermicide and left in place for six to eight hours after sexual intercourse. The diaphragm must be removed after this period. However, the cervical cap can remain in place for up to 24 hours.
Spermicide — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
INTRAUTERINE DEVICES (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. Most are made of molded plastic and include an attached string that projects through the cervix into the vagina, enabling a woman to check that the device remains in place.
The currently available IUDs are safe and effective. These devices include: Copper-containing IUDs prevent pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years. Levonorgestrel-releasing IUDs, prevent pregnancy by thickening the cervical mucus and thinning the endometrium (the lining of the uterus). They also decrease menstrual bleeding by 40 to 90 percent and decrease pain associated with periods. They can be left in place for up to five years, and are highly effective in preventing pregnancy. Some women stop having menstrual periods entirely; this effect is reversed when the IUD is removed.
STERILIZATION — Sterilization is a procedure that permanently prevents a person from becoming pregnant or able to have children. Tubal ligation and vasectomy are the two most common sterilization procedures. Sterilization should be considered permanent, and should only be considered after a careful discussion of all available options with a healthcare provider. (See "Patient information: Surgical sterilization of women" and see "Patient information: Vasectomy").
Tubal ligation — Tubal ligation is a sterilization procedures for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. It may be done at other times as well. A separate topic review is available. (See "Patient information: Surgical sterilization of women").
Essure® — Essure® is a permanent birth control method that requires surgical placement of a tiny coil mechanism into each of the fallopian tubes. The coil blocks the fallopian tubes three months after placement in most women. Placement is done after the woman receives local anesthesia (numbing medicine is injected into the cervix to prevent pain). A back up method of contraception (eg, oral contraceptive or condom) is needed until testing confirms that the fallopian tubes are completed blocked; this is usually performed three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that surgically cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective surgical procedure that can be performed in a doctor's office under local anesthesia. Following surgery, another contraceptive (eg, condoms) must be used for approximately three months, until a semen analysis confirms that there are no sperm present. A separate topic review is available. (See "Patient information: Vasectomy").
OTHER METHODS — Some women and their partners cannot or choose not to use the contraceptive methods mentioned above due to religious or cultural reasons. Alternate birth control options include periodic abstinence and withdrawal.
Periodic abstinence — Periodic abstinence involves trying to predict the time of the month when a woman is most fertile, and abstaining from sexual intercourse during that time. Different methods may be used to help determine the fertile period:
Rhythm or calendar method — This uses the date of the last menstrual period to determine a woman's most fertile period. The first day of the fertile period is calculated by subtracting 18 days from the shortest menstrual cycle. The menstrual cycle is defined as the number of days from the start of one period to the start of the next period. The last day of the fertile period is calculated by subtracting 11 days from the length of the longest cycle. For example, if a woman's menstrual cycle varies from 28 to 30 days, she should refrain from intercourse from days 10 to 19 of each cycle. Day 1 is the first day of bleeding. This method is not appropriate for a woman who has irregular menstrual cycles and women who have recently delivered a baby or who are breastfeeding.
Basal body temperature — This method is based upon changes in body temperature that occur during a woman's cycle. A woman takes her temperature before getting out of bed in the morning; this is called the basal body temperature. Basal temperature rise slightly (about 0.5ยบ F) after release of the egg. Intercourse should be avoided between the start of the menstrual cycle (day one) until three days after the temperature rises. For most women, this requires abstinence for two weeks. This method is not recommended for women who breastfeeding or nearing menopause.
Cervical mucus — This method uses the color, amount, and consistency of a woman's cervical mucus, which change through a woman's cycle. During ovulation, the mucus is typically watery and in larger amounts than at other times. Intercourse should be avoided when watery cervical mucus first appears until three to four days after the heaviest day of mucus production.
When used perfectly, basal body temperature plus cervical mucus monitoring methods are more effective than the calendar or rhythm method. The estimated failure rates are 3 and 9 percent, respectively (show table 1A-1B). However, failure rates may be as high as 86 percent (with a 28 percent risk of pregnancy per cycle) if used incorrectly.
Withdrawal — Also known as coitus interruptus, the withdrawal method requires the man to withdraw his penis from the vagina before ejaculation. Pregnancy may occur if withdrawal occurs too late or if sperm is released before orgasm (in preejaculatory fluid). With this method, contraceptive failure rates may be as high as 18 to 20 percent (show table 1A-1B).
Breastfeeding — Breastfeeding after childbirth has limited effectiveness in preventing pregnancy due to a delay in the return of ovulation. Approximately 88 percent of women who breastfeed exclusively (meaning that no formula is given and the baby is fed on demand) do not ovulate for six months. If the woman does not have a menstrual period, she is more than 98 percent protected from pregnancy for the first six months (show table 1A-1B). Women who use supplemental feeding (formula) and those who menstruate are more likely to ovulate.
It is probably safest to resume a contraceptive in the third month following childbirth for those who breastfeed exclusively and in the third week postpartum for those who do not breastfeed or do so infrequently. A healthcare provider can help to determine the best timing and form of contraception following childbirth.
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov)
National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(www.healthywomen.org)
EngenderHealth
Phone: (212) 561-8000
(www.engenderhealth.org)
Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org)
The Hormone Foundation
(www.hormone.org)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Abma, JC, Chandra, A, Mosher, WD, et al. and the National Center for Health Statistics. Fertility, family planning, and women's health: New data from the 1995 Survey of Family Growth. Vital Statistics; Series 23 No.19.
2. Fu, H, Darroch, JE, Haas, T, Ranjit, N. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56.
3. Steiner, MJ. Contraceptive effectiveness: what should the counseling message be?. JAMA 1999; 282:1405.
4. Trussell, J, Vaughan, B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:64.
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