Recent trends in birth control

Recent trends in birth control – includes related information

Recent trends in birth control

While the inability to conceive is a searing disappointment to those who want a child, preventing pregnancy remains one of the world’s great problems. Of course, we’ve advanced somewhat since the days when women used sea sponges, crocodile-dung pessaries or half a lemon over the cervix to prevent pregnancy. But since the advent of the hormone pill 30 years ago, contraceptive research has focussed mainly on refining existing methods rather than developing new ones. Even some sophisticated modern couples have trouble weighing the pros and cons of contraceptive methods and don’t know which to select. People generally choose different methods at different ages and stages of their sexual lives but continue to demand more of birth control techniques than any other drug or device. A good contraceptive must be easily acquired, reliable, safe, morally and physically acceptable, and convenient to use.

The global contraceptive scene

When talking about birth control, many automatically think of the Pill, although in the U.S. and Canada sterilization is now the leading form of fertility control among married people over 30. During the late ’70s many women shunned the Pill, fearful of its much-publicized cardiovascular side effects, (e.g., heart attacks and strokes). However, the new low-dose preparations are far safer and the Pill remains a favoured contraceptive for many young, sexually active Canadian women. According to 1984 statistics (the latest available) about one and a quarter million women in Canada aged 18 to 49 take the Pill. In Europe, the Pill remains the most popular overall contraceptive.

The IUD or intrauterine device lost favour because of one particular type — the ill-designed Dalkon Shield — which created anxiety about all such devices. But many healthy women still find the IUD a simple, effective contraceptive. Currently there are 70 million IUD users around the world.

For those willing to invest minimal time and effort, barrier methods (e.g., diaphragm, condom, cervical cap) and natural family planning remain widely favoured methods of fertility control, especially in the U.S.S.R., Eastern Europe and Japan. Recently, condoms have made a comeback, often as a second method (to accompany the Pill, diaphragm or IUD), for “safer sex” and protection against sexually transmitted diseases. Condoms are the only currently available safeguard against AIDS. The condom or spermicidals (foams, gels or creams) alone are often the first, most easily obtainable form of birth control tried by young people.

Unhappily, and with predictable results, a large percentage of sexually active teenagers and young people use little or no birth control. According to some estimates, as many as 50 per cent of Canadian teenagers are sexually active but only half of them use any birth control at first intercourse. One University of Toronto study showed that 83 per cent of teens had not planned for or anticipated their first coital act. Of the teen couples who used birth control at first intercourse, about 18 per cent tried withdrawal, 29 per cent used a condom, 30 per cent were on the Pill and the rest relied on vague rhythm methods. A significant number of females engaged in anal or oral sex “from time to time” (presumably as an alternative way of avoiding pregnancy). Most teenagers rely on withdrawal or spermicide and/or condoms as a first method. They shun premeditated forms of birth control because of a lack of confidence, a reluctance to acknowledge sexual activity, mistrust about confidentiality, fear of being “lectured”, and ignorance about where to get advice or supplies. Some feel it’s OK to be sexually “swept away” but not to plan for it. Yet about 80 per cent of women under 30 who use no birth control become pregnant within the first year of becoming sexually active. Many teen pregnancies occur just after a break-up, when each partner experiments with or establishes a new sexual relationship.

Any method safer than pregnancy

Many people don’t realize that any method of birth control is safer than none. The risk of complications or death from pregnancy and childbirth still far outweighs the hazards involved in using any contraceptive. Women aged 15 to 40 are far more likely to be disabled or die from pregnancy than from the Pill or other contraceptives. For example, based on studies with the older Pill formulations, the risk of Pill-related death (due to a stroke, heart attack or lung clot) in a healthy, non-smoking woman under age 35 is 0.6 per 100,000. This compares to the average risk of maternal mortality from pregnancy in Canada of five deaths per 100,000 live births for women of any age. Maternal deaths directly or indirectly due to pregnancy can arise from conditions such as eclampsia (toxemia of pregnancy with elevated blood pressure), a ruptured ectopic pregnancy (outside the uterus), or a lung clot.

For further comparison, the risk of death associated with regular bicycling is 0.9 per 100,000. The only groups for whom the risk of fatal cardiac consequences from the modern, low-dose contraceptive pill may still outweigh the dangers of pregnancy are women over age 30 years who smoke and take the Pill, or women over 40 who take it, whether or not they smoke.

Modern low-dose birth control pills safer

The first hormonal oral contraceptive, developed in the 1950s, triggered a revolution in birth control. For the first time women had access to a reliable, inexpensive way of avoiding unwanted conception. The Pill allowed women to space their babies for better health and family life; gave them control over their own bodies; permitted them to decide whether and when to have a baby and extended many female lives by reducing the toll of unavoidable childbearing. The combination hormone Pill — one of the best studied drugs ever produced — provides effective, reversible birth control and can be used by most healthy women under 35, including teenagers whose periods (menses) have begun. The Pill stops an egg from maturing and prevents its release from the ovary. In those on the Pill, menstruation occurs by “progesterone withdrawal”, not true ovarian cycling. Used consistently and on schedule, the Pill is 99 per cent effective but there is a high discontinuance rate.

The latest multiphasics, introduced in the ’80s, with fewer side effects than earlier forms, are a promising development, increasingly prescribed for first-time Pill users. The multiphasics generally keep the estrogen content stable while varying the amount of progestin through the cycle. Most of the multiphasics contain only one type of estrogen (ethinyl estradiol), with various added progestins. Many women who couldn’t tolerate the side effects of former types find the new Pill acceptable. Experts stress that many reported Pill dangers were due to the earlier high-dose formulations (which contained 80 to 150 micrograms of estrogen and 10 milligrams of progestin), now replaced by lower-dose formulations (with an estrogen content of 35 or less micrograms and one milligram or less of progestin).

For the latest Pill preparations, with a far lower hormonal content than earlier forms, cardiovascular risks aren’t yet known because long-term follow-up studies haven’t been completed. But the new, low-dose Pill is expected to pose minimal cardiovascular dangers (since it has less impact on lipid and carbohydrate metabolism than previous types). Having eliminated or reduced many of the hazards due to the high estrogen content (e.g., hypertension and blood clots), manufacturers are now trying to use different progestins with fewer side effects.

New and safer IUDs (intrauterine devices)

Basically, an IUD is an offshoot of the ancient method of putting pebbles into a camel’s uterus to prevent pregnancy. Inserted through the cervix into the uterus by a medical expert, IUDs come in various shapes, sizes, forms and materials. The “Lippes loop” of the ’60s (an all-plastic, polyethylene device) has been succeeded by newer medicated IUDs that gradually release copper or hormones. In Canada, the Nova-T (with copper over a silver core, left in for five years), and the Gyne-T 380 Slimline or TCu-380S (with copper wire on the arms and stem, left in for four years) are currently available. The Progestasert (hormone-impregnated form, left in for a year) can also be obtained.

IUDs can be inserted at any time into a gynecologically normal woman of childbearing age (with no medical contraindications). But an IUD is usually inserted at the end of or just after a period to avoid putting it into a pregnant woman. Insertion is often recommended right after childbirth (as soon as the placenta is expelled) or after an elective pregnancy termination since medical expertise is then on hand. A new type of IUD, sutured into the uterus with dissolvable stitches, is being developed to reduce post-partum expulsion.

No one knows exactly how the IUD works. It somehow alters the uterine environment, rendering it hostile to implantation of the fertilized egg. The latest research suggests it may also prevent fertilization by injuring sperm or impeding their movement. Hormone-releasing IUDs work by their impact on the uterine lining and cervical mucus. IUDs are considered most suitable for women who have a mutually monogamous sex life, have completed childbearing, or are spacing their families, and do not have dysmenorrhea (painful periods), or medical reasons against their use. The IUD is useful for breastfeeders as it doesn’t affect the quality of breastmilk. Once inserted, an IUD may give no hint of its presence, and require no more than a check after each period to make sure the string is still hanging through the cervix. Should the string not be felt, the IUD may have slipped or been expelled and a medical check-up is needed. IUDs are 98 to 99 per cent effective, better in the second or subsequent years of use.

During the ’70s many women became disenchanted with IUDs because of personally experienced or reported problems, especially heavy periods and pelvic inflammatory disease or PID (a bacterial infection in the ovary and fallopian tubes that can scar the tubes, spread through the pelvis, and cause infertility). Recent research is helping to lift the cloud that has hung over IUDs for the past decade.

The bad press arose over one particular IUD — the Dalkon Shield — which greatly increased pelvic infections, producing infertility and a dramatic rise in mid-trimester septic abortions. Investigation showed the Dalkon Shield to be of poor design, allowing bacteria easy access to the uterus. It was taken off the U.S. market in 1975, and an avalanche of lawsuits made the manufacturer declare bankruptcy in 1985. Fear of litigation cast a bad light on other IUDs and made most U.S. manufacturers suspend production. While copper-bearing IUDs remained available in Canada and elsewhere, by January 1986, only the progesterone-releasing IUD, (Progestasert), was left on the U.S. market. However, in July ’88, a highly effective device (the TCu-380A) — already used by millions of women in the U.K. and Canada — was released for the U.S. market (as ParaGard). Contemporary advances favour copper or hormone-impregnated IUDs, placed high in the uterus (to prevent expulsion), with emphasis on careful insertion and selected choice of users to minimize risks.

Dispelling some unfounded fears about IUDs

Fears about ectopic pregnancy (fetal development outside the uterus), if conception occurs with an IUD in place may be allayed by recent studies which, while controversial, show that copper IUDs do not increase this risk. However, Progestasert IUDs, which pose less risks of PID, have higher ectopic rates than copper forms. Recent Yugoslav data indicate that if a woman gets pregnant with an IUD in place but has the device removed when pregnancy starts, problems are no higher than in non-IUD users. But if the IUD is not removed at an early stage, there’s an elevated risk of mid-trimester septic abortions, premature delivery, stillbirth, and low birth weight (but not birth defects).

Pelvic inflammatory disease (PID) is still a threat even with newer IUDs and 1.3 to eight times higher in users than non-users, depending on the type. New studies show that women in stable, monogamous sexual partnerships using IUDs have little increased PID risks over non-users. And examination of earlier data shows that the risk of PID, greatest during the first few months following insertion, is related more to individual sexual habits (exposure to sexual diseases) than to the IUD. Risks of PID are elevated in IUD users with multiple sex partners. Checking for chlamydia or gonorrhea infections before insertion can cut back risks. Recent studies on giving the antibiotic, doxycycline, concurrently with IUD insertion are underway to see if it will reduce post-insertion PID.

NB: Symptoms of pelvic inflammatory disease include: abdominal cramps or pain, heavier-than-usual or uncomfortable vaginal discharge, possibly a fever. Women with such symptoms, or any who think they may be pregnant (with an IUD in place) should consult their physicians.

Barrier contraceptives

* Condoms plus spermicide. Obtainable without prescription, condoms are thin sheaths of latex or lamb cecum (intestines), put onto the erect penis before genital contact occurs. Most condoms have a reservoir tip to catch the ejaculate (semen) and prevent it from entering the female vagina. One Japanese company manufactures an ultra-thin brand (0.03 mm thick), which may partly explain why so many couples in Japan favour condoms. About 75 per cent of Japanese couples use condoms, compared to only nine per cent of Canadian couples. But neither the Pill nor the IUD is yet generally approved or available in Japan. For full effectiveness, condoms must be used with vaginal spermicide and checked for tears after removal. Condom effectiveness varies from 98 to 80 per cent or less. They are only effective if used correctly for every coital act, and put on before any genital touching. Besides preventing pregnancy, latex condoms protect against syphilis, gonorrhea, genital herpes, and above all, AIDS — but not against the hepatitis B virus which is small enough to pass through both latex and cecum. Since cecum condoms do not effectively protect against STDs, experts strongly advise use of latex types. Some condoms are impregnated with spermicide, which may help to inactivate or kill sperm.

* Diaphragms plus spermicide. The diaphragm, a round or domed, flexible rubber cap (ranging in size from 60 to 90 mm), prescribed and sized by a physician, is used with spermicide. It can be inserted up to six hours before intercourse, and should be left in place for at least six to eight hours afterwards. If intercourse is repeated, more spermicide should be inserted into the vagina. Used according to instructions, diaphragms can be up to 98 per cent effective. After pregnancy, a woman must have her diaphragm resized/refitted. Diaphragms may protect against precancerous changes of the cervical mucosa (tissue), presumed due to the human papilloma or condyloma (wart virus, transmitted from the male penis. A diaphragm plus spermicide also offers some protection against gonorrhea and chlamydia, but not against herpes or AIDS. A diaphragm may elevate risks of urinary tract infections and a few women are allergic to the spermicide, for which a brand change may be the solution. Diaphragms are not advised for anyone with a history of toxic shock.

Cervical cap

Already used worldwide for over 60 years and becoming more popular, cervical caps are available at a few centres in Canada and have just been approved in teh U.S. This thimble-sized, cup-shaped latex device, prescribed by a physician or nurse, fits snugly over the cervix (mouth of uterus) and is held in place by suction. A cervical cap can be inserted by a woman at least an hour before intercourse provided she’s comfortable about handling the genitals. It should be left in for at least six hours after lovemaking. Like the diaphragm, it prevents sperm from entering the cervix. But unlike the diaphragm, a cervical cap doesn’t require more spermicide should intercourse be repeted. Since the cervical cap is smaller, some women find it more comfortable than a diaphragm, but harder to put in and remove. Cervical caps are only prescribed for women with normal Pap smears; and a Pap test should be repeated three months after first use.

The vaginal sponge

Soon to be available in Canada, vaginal sponges are disposable, medicated, polyurethane devices, impregnated with nonoxynol-9, discarded after use. Moistened with water and then inserted deep into the vagina before intercourse, contraceptive sponges will be available without prescription. One size (50 mm diameter) fits all, but because this may be small for some vaginas, barrier-blockage may be imperfect. The sponge must be left in place for at least six hours following intercourse and can be left in up to 24 hours afterwards. It remains effective if intercourse is repeated during tht time, but sponges are not very reliable (with 17 to 24 pregnancies per 100 users). Failure rates are especially high in women who have had children. A small percentage of users experience allergic reactions and some report trouble removing the sponge because it may fragment in the vagina. There have been a few (rare) alleged, but not proven, cases of toxic shock syndrome — an infection involving high fever, low blood pressure and erythroderma (skin scaling and inflammation), generally due to staphylococci. Although blamed for one case (or less) of toxic shock per three million sponges used, studies fail to confirm these figures as the spermicide in the sponge would kill the bacteria responsible for toxic shock. Women can minimize this already low risk by careful adherence to directions.

Spermicides essential with barrier methods

Spermicides are acidic, surface-active chemicals that inactivate or destroy sperm, inserted high in the vagina, near the cervix just before intercourse. Vafginal douching should be avoided for six hours afterwards. Many studies confirm that currently available spermicides do not cause fetal malformation (birth defects). Of types available in Canada, non-oxynol-9 so far beats others because studies show that it kills organisms responsible for gonorrhea, syphilis, warts, herpes, chlamydia, trichomoniasis and AIDS.

Morning-after emergency measures

“Morning-after” emergency measures range from ancient methods such as steaming the genitals or herbal baths to modern post-coital drugs, such as hormones (in Canada) or PC4 (in Britain) and Tetraganon (in Germany). Given in an attempt to forestall pregnancy, these drugs are taken soon after unprotected intercourse. Methods currently being investigated in Canada include high dose estrogens, progestins or both — usually a mixture of enthinyl estradiol with the progestin, dl-norgestrel, or a double dose of monophasic birth control Pills (two twice a day for two days after unprotected intercourse). These post-coital preparations, which may be effective if given up to 72 hours after unprotected intercourse, are only prescribed for emergency purposes after a single act of unprotected or inadequately protected intercourse (e.g., slipped or torn condom). Injection of a new postcoital drug, Ru-486, is also being investigated as a morning-after remedy and proving an effective pregnancy-averter even if given several days after unprotected coitus. Finally, a copper IUD — inserted up to five days after unprotected sex — is another effective “morning after” measure. But an IUD is only inserted for this purpose if the woman would anyway have chosen it as her favoured contraceptive.

Sterilization: should be considered permanent

For couples who want no more children, sterilization is a preferred means of birth control. Despite increasing requests for reversal — because of the three “D”s: death of a spouse, divorce or disaster (losing children) — sterilization is usually difficult to undo. The procedure involves closing off or occluding either the vas deferens (through which the sperm travel) or the fallopian tubes (through which the egg travels). Female sterelization outnumbers vasectomy by seven to five.

* Sterilization of women is done by blocking the tubes, i.e., tying, burning (coagulating) or mechanically closing occluding) them with clips or bands. The procedure is normally done as “day surgery” in hospital. Quite often it is done right after childbirth (once a family is completed), or following abortion. After sterilization the average woman is back to normal activities in a few days. The failure rate is less than 0.5 per cent.

* Sterilization of men is a 20-minute procedure (vasectomy) that involves tying or cuttin the tubes through which sperm travel. A few men have unfounded anxieties about impotence and post-vasectomy spermal antibodies — fears that call for counselling. (The failure rate for male sterilization is the same as for females — under 0.5 per cent).

Counselling is importatn for men and women considering sterilization, to discuss all options and decide which partner should undergo the surgery. Since about five per cent of men and 10 per cent of women suffer post-sterilization regrets, it’s wise to get advice before undertaking this almost irreversible procedure.

Natural family planning

Couples who opt for “natural family planning” (NFP) or “fertility awareness” must limit intercourse to days when ovulation is deemed unlikely. To be successful, a couple must precisely identify the days on which a woman is fertile, and avoid intercourse a week before and a few days afterwards. Since sperm can survive for five days or longer after entering the vagina, the “safe” or infertile time is hard to preduct. Ovulation generally occurs 12 to 16 days before the onset of menstruation. To distinguish fertile from infertile days, the sympto-thermal method employs daily temperature charting, body awareness and observation of mucus flow. Temperature charting relies on a hormone-mediated temperature peak just before ovulation. The cervical mucus-watching or Billings method depends on changes in vaginal mucus. At ovulation, the mucus becomes copious and slippery. Intercourse is considered safe immediately after a period, when there’s no vaginal dampness (“dry days”). Sexual abstinence is necessary for at least three days after the slippery “show”. Failure rates vary widely, ranging from six to 35 per cent. Experts warn that female cycles can be disrupted by emotional upsets, illness or extreme diets. For women not having regular intercourse, the stimulation of a new sexual encounter may trigger ovulation outside the normal fertile time.

Injectable hormonal contraceptives

Injectable hormones such as medroxyprogesterone acetate (Depo-Provera) are widely used in 90 countries. Given every one to six months, progestin injections block egg release for as long as the hormone remains in the body. Since hormone shots eliminate the need for daily pill-swallowing, some medical authorities consider them useful for young women who are reluctant to acknowledge an interest in sex, or unwilling to take responsibility for their sexual behaviour and for the mentally and physically handicapped. Other experts object to the stigma of “irresponsibility” cast on those given long-term contraceptive shots. Depo-Provera is not approved by the FDA and is under review in Canda for use as a contraceptive, although it is allowed in certain conditions (such as: heavy menstrual bleeding, endometriosis and hot flashes). The reluctance to approve Depo-Provera for contraception stems mainly from a few animal studies suggesting a link to benigh breast lumps and elevation of blood lipids. With injected birth control hormones, periods may

cease altogether (a bonus to some), and ovulation can be delayed for up to a year after the last injection wears off. Once inside the body, the injected hormones remain for several months, their effects not reversible until the level drops. Women planning to get contraceptive injections should first evaluate their blood lipids and have them monitored periodically.

Hormonal implants

Hormonal implants, biodegradable or nonbiodegradable, approved in seven European countries and some developing areas (not in Canada), are tiny cylinders containing progestins, inserted under the skin (usually the underarm) by a physician. Contraceptive implants steadily release tiny amounts of hormone, providing reliable contraception for 18 months to five years, requiring little effort or thought. Fertility seems to return to normal once the implants are removed. The well researched Norplant capsule offers reliable contraception for five years. Side effcts include: spotting between periods, menstrual irregularities (in about a quarter of the women who try it), amenorrhea (absent periods), and occasional headaches.

COPYRIGHT 1988 Strategic Inc. Communications Ltd.

COPYRIGHT 2004 Gale Group