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Contraception Choices

Contraception Choices

In Australia, in the past ten years, contraceptive choices for women have increased significantly. Women continue to seek a wide range of contraceptive options and they increasingly want to be fully informed and in control of their fertility. Research indicates that women’s primary concerns when choosing contraception are that it is effective and has minimal side effects. Generally the more effective contraception is the greater the potential for side effects. Ultimately every woman must make their own decision as to what method will suit them best and how they balance the effectiveness of their contraceptive choice with any potential side effects. Younger women will make different choices to older women. Women who have completed their families will make different choices to women who are simply spacing their families. Some women have specific personal, cultural or religious beliefs that make certain forms of contraception unacceptable to them.

Each month a woman’s ovaries release an ovum (egg). Pregnancy may occur if her partner’s sperm reaches this egg and fertilises it. Contraception can help prevent pregnancy occurring; either by stopping the release of this egg, preventing the fertilised egg implanting in the uterus or preventing the sperm reaching the egg. There are several contraceptive methods that work by combining these preventative strategies.

Contraception can be broadly divided into hormonal and non-hormonal methods:

Hormonal methods

There are some hormonal methods of contraception that interfere with breastfeeding. There are also some women who cannot tolerate certain hormones.

The Combined Pill (oestrogen and progesterone pill)
The oral contraceptive combined pill, which contains the hormones oestrogen and progesterone, remains the most popular contraceptive method for younger Australian women aged 18-23.  It prevents the monthly release of an ovum (egg) from a woman’s ovaries. This pill is usually taken for 21 days. A sugar pill, or no pill, is then taken for 7 days. The daily commitment of taking the oral contraceptive pill can be problematic for some women and the newer long-term methods described in this article may be a better alternative. Used correctly the pill is more than 97% effective. You can get some side effects from the combined pill. These are tender breasts, nausea, breakthrough bleeding, headaches, weight gain and changes in libido. These side effects are more common in the first three months of taking the pill. As weight gain and acne are significant to most women, contraceptive pills with newer types of progesterone are being developed to reduce these effects. Expert opinion and research is divided as to whether the combined oral contraceptive pill increases the risk of breast cancer. There is some evidence that ovarian (ovaries) and endometrial (uterus) cancer is reduced in women on the combined oral contraceptive pill.  Women who smoke or are at risk of deep venous thrombosis (blood clots) will be advised of the increased risks to their health of taking the pill. You can’t breast feed on the combined oral contraceptive pill. The advantages of the combined pill are you have a regular period, which is generally lighter. Some pills can actually reduce acne and also help alleviate some of the symptoms of premenstrual syndrome. If you are having a course of antibiotics or some other drugs, or have vomiting or diarrhoea the effectiveness of the pill can be reduced, so seek advice. It is important to remember that the contraceptive pill is not effective immediately and some other form of contraception will also be needed initially.

The Mini Pill (progesterone only pill)
The Mini Pill only contains the hormone progesterone. It changes the mucous at the entrance to the uterus to make to make it difficult for sperm to fertilize an egg. It also alters the lining of the uterus making implantation of a fertilized egg more difficult. It needs to be taken at the same time every day. It can cause side effects of irregular bleeding or missed periods because of the effects it has on the lining of the uterus. The pill is safe to take when breastfeeding. It is a good choice for women who are unable to tolerate the oestrogen in the combined oral contraceptive pill. The Mini Pill is slightly less effective than the combined oral contraceptive pill.

Depo Provera (injectable progesterone)
Depo Provera is an injection of the hormone progesterone that is given every 12 weeks. It prevents ovulation. It is more than 99% effective and can be used when breastfeeding. The disadvantage with this form of contraception is the side effects can last up to 12 weeks without the option of removing or ceasing the hormone, as is possible with other forms of hormonal contraception. It can also take several months after the last injection to become pregnant again. It has some side effects, such as heavy bleeding, irregular bleeding or no bleeding (this is not harmful). Some women report weight gain, headaches and depression.

Implanon (progesterone skin implant)
Implanon is a small plastic rod (4cm long) containing synthetic progesterone that is implanted under the skin of the upper arm. A local anaesthetic is given to numb the area and then the Implanon is inserted under the skin with a sterile applicator. It takes about one minute to insert and about three minutes to remove. Removal involves a small incision being made and the rod is lifted out with little forceps. A pressure bandage will be wrapped around the arm for 24 hours following insertion and removal to minimize bruising. It prevents ovulation and also has a secondary effect on the lining of the uterus and cervical mucous. It is one of the most effective contraceptive methods available, with a failure rate of 0-0.7% (more than 99% effective). It needs to be replaced every three years. It has the side effect of irregular bleeding or changes in menstruation. It is ideal for women wanting long-term contraception. Implanon is also ideal for women who can’t take oestrogen. It is quickly reversible, with pregnancy possible soon after removal. Women can also breastfeed with Implanon. There has been some controversy in the media about Implanon not being inserted properly and left behind in the applicator. You should be able to feel the small plastic rod under your skin and this will let you know the Implanon has been inserted correctly. You can also ask to check the Implanon rod is no longer in the applicator after insertion.

Mirena (progesterone intrauterine device)
Mirena is a small plastic T-shaped device, which is inserted into the uterus. It carries the hormone progesterone in a sleeve around its stem and has two fine threads attached to its base. It is inserted through the vagina using a thin tube. Insertion only takes a few minutes. The progesterone is gradually released and this causes the cervical mucous to thicken which inhibits the sperm’s movement. Mirena also reduces the monthly lining of the uterus, resulting in lighter, shorter periods. The device is effective for five years before it needs to be replaced. It has a failure rate of 0.2% (98% effective). Mirena is ideal for those women wanting long-term contraception. On removal, your usual level of fertility should return quickly. Women with painful or heavy periods may find it particularly useful. Women generally have spotting or light bleeding in addition to their periods for the first 3 to 6 months after the device is fitted. Overall, however, the amount of bleeding is reduced and for some women periods stop all together. It can be fitted from six weeks following the birth of a baby and women can breastfeed after insertion of Mirena

Emergency contraception ‘morning after pill’ (progesterone pills)
If you have had sex and not used contraception, or the condom broke, then you can take the emergency pill, commonly known as the ‘morning after pill’. This pill contains the hormone progesterone and can be used while breastfeeding. Two tablets need to be taken together or at a 12 hour interval within 24 hours of unprotected intercourse. The emergency contraception works by delaying ovulation and preventing implantation. The pills can cause irregular bleeding and a possible increase in ectopic pregnancy if the method fails. It is important that women don’t rely on the emergency pill for contraceptive protection but seek to have a more effective method in place.

Non-Hormonal methods

All non-hormonal methods can be used when breastfeeding. Women who rather not take extra hormones into their bodies or cannot tolerate them will find non-hormonal methods more acceptable. They are, however, less effective than the hormonal methods described.

Male and female Condoms
Condoms (male and female) have the unique advantage of protecting both men and women against sexually transmitted infections as well as pregnancy. Condoms can be 85-95% effective. Most condoms are supplied with ready lubrication. Using an additional water-based lubricant such as KY Jelly helps prevent the condom from breaking. Water-based lubricants should always be used with latex condoms rather than oil based products such as baby oil, as these can cause the condom to split. Condoms can be used with other forms of contraception. People with more than one partner should use condoms along with other forms of contraception to reduce the chance of contracting sexually transmitted diseases. Condoms can be bought in a variety of sizes and colours, are relatively inexpensive and are available in most supermarkets and chemists.

The male condom is a rubber sheath worn over the man’s erect penis and it collects sperm stoping them entering the vagina and uterus. The only side effect of condom use can be a latex allergy. As latex is perishable condoms should be kept in a cool place and used by the expiry date on the package. The female condom suits some women who like to be in control of the contraception. The woman places this condom inside the vagina before intercourse and the penis goes inside the condom. The female condom covers some of the vulva and may provide better protection against sexually transmitted infections such as herpes and human papilloma virus

Polyurethane condoms (both male and female) have recently been made available in Australia. These have the benefits of not containing latex allergens, being stronger than conventional condoms and having better heat transmission. Polyurethane condoms are, however, more expensive than conventional latex.

Intrauterine device (IUD)
The IUD is a plastic and copper device placed in the uterus. It prevents the fertilised ovum embedding in the uterus. It is about 98% effective. It can cause heavier and/or longer periods and cramping. There is also an increased risk of infection in the uterus and tubes, which could lead to infertility. For this reason some doctors are very reluctant to insert IUDs, particularly in women who have not had children yet. Its advantages are it is effective immediately and can remain in place for 5 to 8 years. It works out to be quite an economical contraceptive device over time.

Diaphragms
Diaphragms are made out of a soft, very flexible rubber. They placed inside the vagina so they cover the cervix. This prevents sperm entering the uterus. It is advisable to always use a spermicidal cream or jelly with diaphragms. They come in all different sizes and need to be fitted by a doctor or nurse trained in their use. They also need to refit the diaphragm if you lose or gain weight (3.5kg) or have a baby. They can be fitted about six weeks following the birth. They are 92-96% effective if used with a spermicide. The advantage of this form of contraception is you only need to use it when having sex. It can also be used when the woman is having her periods. It can be washed and reused again and lasts for about 1-2 years. The disadvantages are you have to put it in before and leave it in for six hours after you have sex. Some women find the insertion and removal of the diaphragm difficult and a few people are allergic to rubber. Some women for cultural or personal reasons don’t like the fact that they have to touch their genitals.

Breastfeeding
Breastfeeding as a form of contraception can be up to 98% effective and it is probably the most commonly used contraception to space children worldwide. Breastfeeding works as by keeping levels of the hormone prolactin high and this prevents women ovulating. In order for breastfeeding to be an effective contraception women need to be breastfeeding their babies for six months, at regular intervals throughout the day and night (around every four hours). The baby must have no other food or drinks. This will insure breastfeeds are not missed. Menstrual periods also must not have returned. For women not wanting to get pregnant again under any circumstance there is a need to use other forms of birth control than breastfeeding.

Male and Female sterilization
Male and female sterilization must be viewed as a permanent method of contraception. In 2001 9% of women and 11% of men opted for a sterilization procedure in Australia. For women sterilization involves cutting the fallopian tubes or using clips to block them. This prevents the ovum passing through the fallopian tube and being fertilized. Young women who have many years of childbearing potential ahead will find doctors very reluctant to perform a sterilization operation on them. The decision for female sterilization should not be taken lightly. Female sterilization is a highly effective form of contraception with over 99% effectiveness.

For males sterilization involves cutting the vas deferens, which is the tube that carries the sperm from the testicles to the penis. This operation involves a local anaesthetic injection and small operation.  Two negative specimens are required before it is considered a safe contraceptive method. This can take as long as eight weeks following the surgery. Vasectomy has an effectiveness of over 99%. Successful reversal of both male and female sterilization is low and should be considered very carefully. Sterilization techniques are improving all the time so they are less invasive.

‘Natural’ fertility methods
Contraceptive methods such as rhythm, billings, mucous, ovulation and temperature are all names for methods some women use to tell when they are most fertile and most likely to become pregnant.  These methods are harder to use if a woman has irregular periods. They also take practice, close monitoring and a good knowledge of your body to use successfully. Women of certain cultural and religious backgrounds prefer to use ‘natural fertility methods.’ Make sure you get adequate information before embarking on these methods.

The future

New methods of contraception such as skin patches, and vaginal rings, which will deliver oestrogen and progesterone, may soon be available in Australia

For information about contraception you can consult your doctor, midwife, women’s health nurse or family planning centre. For all contraceptive methods discussed here consult your health provider for further information on the contraception of your choice.

Dr Hannah Dahlen is the Associate Professor of Midwifery at the University of Western Sydney. She has been a midwife for more than 20 years. Hannah is also an executive member of the Australian College of Midwives, NSW Branch. She has researched women's birth experiences at home and in hospital and published extensively in this area. Hannah's website is www.hannahdahlen.com.au

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