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Contraception

Introduction

Contraception is about choices. There is no right or wrong method of contraception, each couple will have different views, needs and tolerances for each contraceptive method.

Information on contraception is exhaustive and can be overwhelming and confusing. The intention of this page is to provide a brief, easy to understand summary of each contraceptive method with some added thoughts from Dr Friebe.

Methods of contraception

Condoms

Condoms have been used since the 1500’s at least. Initially they were used for prevention of sexually transmitted diseases, an advantage still in their use today. Condoms need to be used correctly, for every single act of sexual intercourse, rolled on to the erect penis BEFORE intercourse starts to be 98% effective.

Put another way, 2% of female partners using condoms solely for their contraception perfectly correctly and every time will fall pregnant per year. In the real world, where people are people and forget to use a condom, or use the condom incorrectly, the pregnancy rate is about 18%.

Ease of use, comparatively few side effects and easy availability are the main advantages of condoms. Need for discipline in their use, and obvious failure rates in the real world are the disadvantages.

Female condoms are also an option, but don’t seem to be widely as used.

Contraceptive Pill

First used in the 1960’s, the oral contraceptive pill is a very popular form of contraception and is now estimated to be used by at 100 million women worldwide.

Effects

As well as preventing pregnancy, the contraceptive pill also has the added benefits of:

  • reducing period blood loss
  • reducing period pain and pelvic pain in general associated with gynaecological organs
  • suppressing endometriosis recurrence in women who have had endometriosis diagnosed and resected before.
  • regulating periods, especially helpful for women diagnosed with polycystic ovarian syndrome (PCOS), who often have an absent or irregular period.
  • suppression of acne and hair growth (when this is a problem, especially in PCOS) by supressing testosterone levels.
  • help in reducing pre-menstrual tension, menstrual migraines and other pre-menstrual mood issues by softening the fall in oestrogen levels which precede the period naturally. This will often be a factor in the mentioned symptoms.

How does it work?

The contraceptive pill contains 2 hormones, oestrogen and progesterone. These hormones act together to suppress the pituitary gland, (located in the brain) from secreting a hormone called Follicular Stimulating Hormone (FSH) which in turn stimulates the ovary to make a dominant follicle, which contains the egg.

Another mode of protection is the progesterone hormone effect on the cervical mucus, causing it to thicken to keep sperm out and impede their passage through the cervix into the uterus.

Success rates

If used perfectly correctly, the failure rate of the contraceptive pill is about 0.3%, or about 3 women per 1000 all taking the contraceptive pill will become pregnant in a year.

Once again though, in the real world, several factors can reduce the pill’s effectiveness.

  • Mistakes, by the user missing pills or not starting the pill at the correct time.
  • By the doctor in not explaining correctly how to use the pill.
  • Non-compliance by the user, it you don’t take it, it won’t work!
  • Vomiting or diarrhoea leading to intestinal malabsorption of active pills. This will then lead to the pituitary being able to secrete FSH to lead to ovulation.
  • Drug interactions with active pills that decrease estrogen or progestogen levels, thus once again allowing the pituitary to secrete its FSH to lead to an ovulation. Antibiotics and anti-epileptic medications are the big culprits here.

Correct use

Generally, the first active pill is taken on the first day of the menstrual period. There will often be a coloured section, usually green, with the days of the week marked, and the first active pill is to be taken on the day of week in the green section and then followed around.

After 21 days, the pill taken changes to a placebo non-hormone containing pill, or a “sugar pill”, and the period will begin in this 7 day sugar pill time. When the period starts, the next packet will begin in the green section again on the day of the week of the period commencing. If the woman wishes to miss her period, be it for medical or social reasons, the sugar pills at the end of the packet are skipped and the active pill in the next packet is taken instead and the active pills are continued with. A woman can actually miss as many periods as she likes, for many though after missing 3-4 periods in a row, some breakthrough bleeding and spotting may occur. This will often mean the endometrial lining of the uterus has become too thin, and a period will need to happen at the end of the pill packet by taking the sugar pills and shedding the overly thin endometrium.

Nuva Ring

The Nuva Ring is a small thin flexible ring inserted into the vagina that slowly delivers the same hormones as the contraceptive pill- oestrogen and progesterone, over a 3-week period of time. After 3 weeks, the woman removes the ring and will have a period, or if she wishes to miss her period, a new ring can be immediately inserted.

The Nuva Ring is a good option for women who may feel nauseated from taking the contraceptive pill, who forget to take a pill every day, or who may have issues with spotting and irregular bleeding despite trying different strengths of contraceptive pill without success.

Implanon

The Implanon is a small implant placed under the skin of the arm, just along the line of the bicep muscle. It slowly secretes progesterone hormone into the body over 3 years, preventing pregnancy by thickening the mucous of the cervix to prevent sperm entry, keeping the lining the uterus thin to prevent implantation of any early pregnancy, and also suppression of ovulation by acting on the pituitary gland.

The Implanon is an excellent contraceptive; well over 99% success for preventing pregnancy and it has the advantage of the woman not having to remember to take a pill every day. The major disadvantage is a high number of women will eventually begin to bleed irregularly and spot bleed frequently, and removal of the Implanon is the only solution that really works. Weight gain and mood symptoms can also be an issue.

Mirena

The Mirena is an intrauterine device, shaped like a small “T”, which is inserted into the uterus for contraception.

The Mirena prevents pregnancy by:

  • Thickening the cervical mucus to prevent sperm entry into the uterus
  • Inhibiting the sperm from reaching the egg
  • Thinning down the endometrial lining of the uterus to prevent any implantation of an early pregnancy.

The Mirena is highly effective at preventing pregnancy, well over 99% reliable. It also has the added advantage of secreting progesterone hormone within the uterus, keeping the endometrial lining of the uterus thin and stable at all times. This causes the period blood loss to cease altogether, or to be extremely light each month. The Mirena can remain in the uterus for 5 years, and once it is inserted into the uterus, the woman will be covered for contraception.

The Mirena is usually easily inserted under a local anaesthetic in the rooms by Dr Friebe. It usually takes 5-8 minutes and most women tolerate the procedure very well. Very occasionally, the cervix may be too tight or too scarred to insert the Mirena into the uterus easily under a local anaesthetic, and thus a general anaesthetic in theatre by an anaesthetist may be required for successful Mirena insertion.

Most women are very happy with Mirena and have no issues.

When there are issues with the Mirena, they tend to be the following:

  • Persistent spotting and irregular bleeding.
  • Persistent cramping pains that don’t settle after insertion.
  • Weight gain (if the Mirena is the culprit, any weight gain is usually fluid retention. Remember weight gain can have multiple causes!)
  • Mood changes.

The Mirena is usually easily removed by pulling on the strings attached to the Mirena which extrude from the cervix. Occasionally the strings can curl up into the cervix and not be visible; Dr Friebe can usually overcome this with a few tricks and techniques!

Sterilisation

Sterilisation can be performed on the male or the female of the couple. The most important aspect to this form of contraception is for the couple to realise it is needs to be considered PERMANENT and no more babies are desired.

Men will undergo a vasectomy, which is a transection of the tube called the vas deferens that brings the sperm into the semen ejaculate. Interruption of this tube leads to the semen being free of sperm within 3 months of the procedure. The male will generally see his own GP for a referral, and be sent on to the appropriate surgeon who will explain further details.

Women can be sterilised by a short laparoscopic pregnancy called a tubal ligation. In this procedure, under a general anaesthetic in theatre, a small camera called a laparoscope is inserted through the belly button into the abdomen. The abdomen is then filled with gas, an instrument is passed through a small cut on the bikini line of the abdomen, and a permanent clip is placed onto each Fallopian Tube. This will disrupt the sperm and egg meeting and fertilising in the Fallopian Tube.

This is performed as a day procedure and women generally fully recover within 2-3 days. The procedure is quite low risk, there are some rare risks and complications of course, as there are for any surgery, and these will be explained by Dr Friebe when the surgical consent form is signed.