Patient education: Birth control; which method is right for me? (Beyond the Basics)

INTRODUCTION — There are many methods available to help prevent pregnancy, with some of the most popular including condoms and birth control pills. Deciding which method is right can be tough because there are many issues to consider, including costs, future pregnancy plans, side effects, and others.

This article reviews all methods of birth control. More detailed discussions of hormonal, long-term, and barrier birth control methods are available separately. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)" and "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)" and "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

EFFECTIVENESS OF BIRTH CONTROL — Birth control methods vary widely with respect to their effectiveness. Contraceptives can fail for a number of reasons, including incorrect use and failure of the medication, device, or method itself.

Certain birth control methods, such as intrauterine devices (IUDs) and the implant have the lowest risk of failure (pregnancy). This is because they are the easiest to use properly. You should consider these methods if you want the lowest chance of a mistake or failure, which could lead to pregnancy. (See "Patient education: Long-acting methods of birth control (Beyond the Basics)".)

Overall, birth control methods that are designed for use at or near the time of sex (eg, condoms, diaphragm) are generally less effective than other birth control methods (eg, the IUD, the implant, and birth control pills).

If you forget to use birth control or if your method fails, there are options to reduce your risk of becoming pregnant for up to five days after you have sex. This is known as emergency contraception. (See "Patient education: Emergency contraception (Beyond the Basics)".)

CHOOSING A BIRTH CONTROL METHOD — It can be difficult to decide which birth control method is best because of the wide variety of options available. The best method is one that you will use consistently, is acceptable to you and your partner, and does not cause bothersome side effects. Other factors to consider include:

●How effective is the method?

●Is it convenient? Do I have to remember to use it? If so, will I remember to use it?

●Do I have to use/take it every day?

●Is this method reversible? Can I get pregnant immediately after stopping it?

●Will this method cause me to bleed more or less? Will the bleeding I have while using the method be predictable or not predictable?

●Are there side effects or potential complications?

●Is this method affordable?

●Does this method protect against sexually transmitted diseases?

●Will it be difficult to discontinue this method if I choose to do so?

You should also consider how easy it is to get your birth control. For some forms, you need to see a doctor for a prescription. But there may be other options; for example, in some areas, you can get birth control pills online through services such as Nurx (www.nurx.com) or PRJKT RUBY (www.prjktruby.com). There are other online resources available as well.

No method of birth control is perfect. You must balance the advantages and disadvantages of each method and then choose the method that you will be able to use consistently and correctly.

INTRAUTERINE DEVICES (IUD) — IUDs are placed by a health care provider through the vagina and cervix, into the uterus. The currently available IUDs are safe and effective. These devices include:

●Copper-containing IUD – The Copper-containing IUD remains effective for at least 10 years, but can be removed at any time. The Copper IUD does not contain any hormones. Some people have heavier or longer bleeding during their period while using a copper IUD.

●Levonorgestrel-releasing IUD – The levonorgestrel-releasing IUD (which is available in different sizes and doses) releases a hormone, levonorgestrel, which thickens the cervical mucus and thins the endometrium (the lining of the uterus). This IUD also decreases the amount you bleed during your period and decreases pain associated with periods. These hormone-containing IUDs can be left in place for up to three to eight years (depending on the type of IUD chosen) but can be removed at any time. They are highly effective in preventing pregnancy. Some people stop having menstrual periods entirely; this effect is reversed when the IUD is removed.

BIRTH CONTROL IMPLANT — A single-rod progestin implant, Nexplanon, is available in the United States and elsewhere. It is inserted by a health care provider into your arm and is highly effective in preventing pregnancy. While it prevents pregnancy for at least 3 years as the hormone is slowly absorbed into the body, it can be removed at any time. It is effective within 7 days following insertion. Irregular bleeding is the most bothersome side effect. Fertility returns quickly after the rod is removed. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

INJECTABLE BIRTH CONTROL — The only injectable method of birth control currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera). This is a progestin hormone, which is long-lasting. DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A version that is given under the skin is also available.

DMPA is very effective, when used consistently. A full discussion is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

Side effects — The most common side effects of DMPA are irregular or prolonged vaginal bleeding and spotting, particularly during the first three to six months. Up to 50 percent of people completely stop having menstrual periods after using DMPA for one year. Although ovulation and menstrual periods generally return within six months of the last DMPA injection, it can take up to a year and a half for ovulation and cycles to return. For this reason, DMPA should be used only by people who do not wish to become pregnant in the next year or longer.

BIRTH CONTROL PILLS — Most birth control pills, also referred to as "the pill," contain a combination of two female hormones. A full discussion of birth control pills is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

How well do they work? — When taken properly, birth control pills are effective. In general, if you miss one pill, you should take it as soon as possible. If you miss two or more pills, continue to take one pill per day and use a back-up method of birth control (eg, a condom) for seven days. If you miss two or more pills, you should also consider taking the morning after (emergency contraception) pill. (See "Patient education: Emergency contraception (Beyond the Basics)".)

Side effects — Side effects of the pill include:

●Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months.

●Irregular vaginal spotting or bleeding. This is particularly common during the first few months. Forgetting a pill can also cause irregular bleeding.

Progestin-only pills — Unlike traditional birth control pills, the progestin-only pill, also called the mini pill, does not contain estrogen. It does contain progestin, a hormone that is similar to the female hormone, progesterone. This type of pill is useful for people who cannot or should not take estrogen.

Progestin-only pills are as effective as combination pills if they are taken at the same time every day. However, the norethindrone progestin-only pill becomes less effective if you are more than three hours late in taking it, in which case, emergency contraceptives may be considered. This concern does not apply to a newer progestin-only pill that contains drospirenone.

SKIN PATCHES — Birth control skin patches contain two hormones, estrogen and progestin, similar to birth control pills, and may be preferred by some people because you do not have to take them every day. Although birth control skin patches are as effective as birth control pills in people who are categorized as "normal weight" based on their body mass index (BMI), they are less effective in those who fall into the overweight category.

One of the skin patch birth control methods available in the United States is sold under the brand name Xulane. A newer skin patch (brand name: Twirla) releases a lower amount of estrogen than Xulane. You wear the patch for one week on the upper arm, shoulder, upper back, or hip. After one week, you remove the old patch and apply a new patch; you repeat this for three weeks. During the fourth week, you do not wear a patch and withdrawal bleeding occurs during this week. Each new patch should be started on the same day of the week.

The risks and side effects of the patch are similar to those of a birth control pill, although there may be a slightly higher risk of developing a blood clot. Because obesity (having a BMI of 30 kg/m² or greater) alone is a risk factor for developing a blood clot, people who fall into this category should not use birth control skin patches.

VAGINAL RING — A flexible plastic vaginal ring contains estrogen and a progestin. You insert the ring in your vagina, where hormones are slowly absorbed into your body. You wear the ring inside the vagina for three weeks, followed by one week when you do not wear the ring; bleeding occurs during the fourth week. With one type of ring (sample brand names: NuvaRing, EluRyng), a new ring is placed each four weeks. With the other type (brand name: Annovera), the same ring is used for up to one year (13 28-day cycles). The vaginal ring prevents pregnancy similarly to the birth control pill, and the risks and side effects are similar. More information about the vaginal ring is available separately. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)".)

BARRIER METHODS — Barrier contraceptives prevent sperm from entering the uterus. Barrier contraceptives include the condom, diaphragm, and cervical cap. A full discussion of barrier methods of birth control is available separately. (See "Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)".)

External condom — The external (formerly male) condom is a thin, flexible sheath placed over the penis to prevent semen from entering the partner's body. To be effective, it is important to carefully follow instructions when using condoms, and to use them every time you have sex. Many people who choose another method of birth control (eg, pills) also use condoms to decrease their risk of getting a sexually transmitted infection (STI). External condoms can also be used during anal sex to lower the risk of STIs.

Internal condom — The internal (formerly female) condom is worn inside the vagina to prevent semen from entering. It is a sheath made of polyurethane and is prelubricated. One ring-shaped part of this method remains inside the vagina while a second ring-shaped part remains outside the vagina.

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 sex. 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, sponge, suppository, and tablet.

PERMANENT BIRTH CONTROL — This is a procedure that permanently prevents you from becoming pregnant or getting a partner pregnant. Tubal ligation and vasectomy are the two most common permanent birth control procedures. These procedures are permanent, and should only be considered after you discuss all available options with a health care provider and if you are certain you wish to permanently prevent pregnancy. (See "Patient education: Permanent birth control for women (Beyond the Basics)" and "Patient education: Vasectomy (Beyond the Basics)".)

Tubal ligation — Tubal ligation is a procedure that surgically cuts, blocks, seals or removes the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Tubal ligation can be performed at the time of cesarean birth ("c-section"), or in the hospital following vaginal delivery. The procedure may be done at another time as well. This is discussed in more detail separately. (See "Patient education: Permanent birth control for women (Beyond the Basics)".)

Vasectomy — Vasectomy is a procedure that cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective procedure that can be performed in a doctor's office under local anesthesia. Following vasectomy, you must use another method of birth control (eg, condoms) for approximately three months, until testing confirms that no sperm are present in the semen. This is discussed in more detail separately. (See "Patient education: Vasectomy (Beyond the Basics)".)

OTHER BIRTH CONTROL METHODS — Some people cannot or choose not to use the birth control methods mentioned above due to religious, cultural, or personal reasons. Fertility-awareness based methods for preventing pregnancy are based upon the physiological changes during the menstrual cycle. These methods, also called "natural family planning," involve identifying the fertile days of the menstrual cycle using a combination of cycle length and physical manifestations of ovulation (change in cervical secretions, basal body temperature) and then avoiding vaginal sex or using barrier methods on those days. Smartphone apps are available that may help with tracking cycles.

The effectiveness of fertility-awareness methods in preventing pregnancy is lower than for the methods detailed above.

EMERGENCY CONTRACEPTION — Emergency contraception refers to the use of medication after unprotected sex to prevent pregnancy. Types of emergency contraception include the levonorgestrel or copper intrauterine device (IUD) or pills. You can use emergency contraception if you forget to take your birth control pill, if a condom breaks during sex, or if you have unprotected sex for other reasons (including victims of sexual assault). An IUD can be inserted for use as emergency contraception and is much more effective at preventing a pregnancy than pills. It is the best choice for emergency contraception, and you can continue to use it as your ongoing method of birth control. The other options are morning after pills, which may be hormonal (eg, Plan B One-Step, which is available without a prescription) or nonhormonal (eg, Ella, available only by prescription). Detailed information on emergency contraception is available separately. (See "Patient education: Emergency contraception (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem. An excellent website to help you choose a method of birth control is www.bedsider.org.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Choosing birth control (The Basics)
Patient education: Long-acting methods of birth control (The Basics)
Patient education: Hormonal birth control (The Basics)
Patient education: Permanent birth control for women (The Basics)
Patient education: Barrier methods of birth control (The Basics)
Patient education: Intrauterine devices (IUDs) (The Basics)
Patient education: IUD insertion (The Basics)
Patient education: IUD removal (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Barrier and pericoital methods of birth control (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Emergency contraception (Beyond the Basics)
Patient education: Permanent birth control for women (Beyond the Basics)
Patient education: Vasectomy (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Intrauterine contraception: Candidates and device selection
Contraception: Counseling for females with obesity
Contraception: Counseling for women with inherited thrombophilias
Contraception: Issues specific to adolescents
Depot medroxyprogesterone acetate (DMPA): Formulations, patient selection and drug administration
Emergency contraception
Internal (formerly female) condoms
Fertility awareness-based methods of pregnancy prevention
Hormonal contraception for menstrual suppression
Pericoital (on demand) contraception: Diaphragm, cervical cap, spermicides, and sponge
Hysteroscopic female permanent contraception
Contraception: Etonogestrel implant
External (formerly male) condoms
Intrauterine contraception: Management of side effects and complications
Evaluation and management of unscheduled bleeding in individuals using hormonal contraception
Contraception: Counseling and selection
Combined estrogen-progestin oral contraceptives: Patient selection, counseling, and use
Contraception: Postpartum counseling and methods
Contraception: Progestin-only pills (POPs)
Combined estrogen-progestin contraception: Side effects and health concerns
Female interval permanent contraception: Procedures
Contraception: Transdermal contraceptive patches
Vasectomy

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/birthcontrol.html, available in Spanish)

●Planned Parenthood Federation of America

Phone: (212) 541-7800

(https://www.plannedparenthood.org/learn/birth-control)

●Bedsider – A site that provides information on birth control for people ages 18 to 29 years run by the nonprofit Power to Decide

(http://bedsider.org)

●Center for Young Women's Health – A site by Boston Children's Hospital that provides general and sexual health information for teens and young adults

(http://youngwomenshealth.org)