So you really don’t want to become pregnant

So you really don’t want to become pregnant  

MESSAGE:

4 possible recommendations for all women and men:

  1. If there is any doubt at all as to whether you are protected against an unwanted pregnancy, the next time it looks as though sexual intimacy is about to lead to vaginal intercourse, definitely use abstinence, outercourse, a condom or withdrawal until you know where you stand. 
  2. 2.                 When starting to use a hormonal contraceptive and there is any doubt in your mind as to WHEN it becomes effective, use it for 7 days before you count on the hormonal method as your sole contraceptive. During those 7 days use abstinence, a condom, outercourse or withdrawal.
  3. For many, many women who are young and will have a number of different partners (4, 6, 8, 10 or more) before trying to become pregnant, dual protection every single time using condoms makes so much sense.  Most women who become infertile due to pelvic infections have never once been treated for PID (pelvic inflammatory disease).  Chlamydia is treacherous.  Dual protection using condoms consistently prevents infections and also increases contraceptive effectiveness.
  4.  You are 20 times more likely to become pregnant using pills, patches or rings than if you use an implant (Nexplanon or Implanon) or an IUD (the copper T IUD called ParaGard or the Levonorgestrel IUD called Mirena.

When contraceptive effectiveness is very important AND your ability become pregnant in the future is also important, use one of the Long Acting Reversible Methods (often called the LARC methods) AND CONDOMS.     

“You may copy parts of or all of this 4 page 11” x 17” presentation without asking for permission.

Please credit as follows:   So you don’t want to become pregnant”; Robert A. Hatcher, MD, MPH; July 1.

The Levonorgestrel IUD called Mirena: Background INFO:

  • Mirena is as effective as most forms of female sterilization
  •  In the first month or so, Mirena causes increased days of bleeding and may also cause cramping/pain.  One clinician who has inserted 200 IUDs in the past year tells her patients: “You may dislike Mirena for a month, but then you are going to love it for 5 years.”
  • Women using Mirena lose 90-95% less blood and have less pain than women using no hormonal contraceptive. Endometriosis, bleeding from uterine fibroids, endometrial hyperplasia and endometrial cancer are prevented and treated by Mirena IUDs.
  • Over time IUDs are the most cost effective methods ever developed for women who want to become pregnant in the future.
  • Appears to have about a 50% protective effect against upper genital tract infections (pelvic inflammatory disease).

Most important suggestions:

  1.  The Mirena IUD can be used for at least 7 years and probably for 10 years [Speroff and Darney; Clinical Guide for Contraception; p.249;2011]
  2. If the string of your Mirena IUD becomes longer your uterus may be expelling your IUD. Use condoms and see your clinician right away.
  3. If the price quoted to insert this IUD is too high, look around.  You may find a lower price somewhere else.

The Copper T 380 A IUD called ParaGard: Background INFO:

  • No hormones at all.
  • Most women continue to have regular periods using a ParaGard IUD. 
  • Pain, cramping and the amount of blood lost all may increase in users of a copper IUD.

Most important suggestions:

  1. If you have sex without a contraceptive copper IUDs are by far the most effective emergency contraceptive and then can provide at least 12 years of contraception!
  2. If the strings of your copper IUD become longer your uterus may be expelling your IUD. Use condoms and see your clinician right away.
  3. If the price quoted to you to insert this IUD is too high, look around.  You may find a lower price somewhere else.
  4. While copper T 380 A IUD is approved for 10 years it remains effective for 12 years and studies have found no pregnancies from the 12th to the 20th year.

Nexplanon and Implanon implants: Background INFO:

  • Implanon has the lowest failure rates of all the reversible contraceptives
  • Over time, spotting and breakthrough bleeding diminish.

Most important suggestions:

  1.              Implanon has an immediate contraceptive effect if inserted within the first 7 days of the start of a period, but when insertion is after day 7, a backup method is required for at least 3 days. [Speroff and Darney; Clinical Guide for Contraception; p.192;2011]
  2.               If you choose to use a Nexplanon or Implanon implant, it will provide you THE MOST EFFECTIVE contraception of all female methods for 4 years
  3.             This is the method that most effectively stops ovulation making it most acceptable for women whose religion cannot accept a method that works by stopping implantation.

“The Pill” providing BOTH an estrogen and a progestin: Background INFO:

  • If a woman starts a year using pills as her contraceptive she has a 9% chance of becoming pregnant in the next year. [Trussell J, Guthrie KA Contraceptive Technology; 2011, p50]
  • Due primarily to inconsistent use, in the United States one million women become pregnant each year using pills as their contraceptive. [Nelson A and Cwiak C Contraceptive Technology ; 2011; p 249]

Most important suggestions:

  1.          Go to Bedsider.com and have them remind you on your cell phone or i pad to take your pill each day at the same time.
  2.          Keep your pills in your pocketbook. Then you can take a forgotten pill as soon as you realize you forgot it and take your pills on schedule if you are away from home for a night or for a longer trip.
  3.           If you have experienced pregnancy/pregnancies using pills or have difficulty remembering to take pills, strongly consider switching to an IUD or an implant.
  4.           The drugs that decrease the effectiveness of hormonal contraceptives by increasing liver hormone breakdown are listed below:               

Carbamazepine (Tegretol), Nevirapine, Oxcarbazepine (Trileptal), Phenobarbital, Phenytoin (Dilantin),

Primidone (Mysoline), Rimidone (Mysoline), Rifabutin, Rifampicin, St. John’s Wort,

Topiramate (Topamax), Lamotrigine (Lamictal)*

*Lamictal is, itself affected by pills and pills affect Lamictal

Mini-pills” are pills that provide ONLY a progestin: Background INFO:

  • Mini-pills are really the easiest pills to take. You take one pill every single day no days off and no placebo pills). All the pills are exactly the same.
  • Mini-pills or progestin-only pills (POPs) can be used by almost all women
  • Mini-pills are less dangerous and can be used by women who have had a blood clot, by breastfeeding women and by women over 35 who smoke
  • 2-4 hours after taking a mini-pill it causes increased thickening of cervical mucus AND THEN, MOST IMPORTANTLY, thickened cervical mucus lasts for just 22 hours after taking a mini-pill. [Speroff and Darney; Clinical Guide for Contraception; p.158;2011]

Most important suggestions:

  1.    Taking mini-pills at night is NOT a good idea if nighttime is when you will usually have intercourse.
  2.    If you usually have sex at night or on awakening in the morning, take your mini-pills at mid-day or in the early afternoon.

3.  You must take one pill every day.  All pills are exactly the same. No pills are placebo pills.

Depo Provera injections or “the  shot”: Background INFO:

  • Each Depo shot remains effective for 17 weeks(just under 4 months) not for just 13 weeks (3 months)
  • Depo injections are THE MOST PRIVATE of all reversible methods
  • Bone density falls while using Depo but returns to normal when it is stopped
  • Irregular bleeding is the most common reason for stopping use of Depo-Provera
  • Weight gain is a problem, particularly for women who are already overweight when they start using Depo

Most important suggestions:

  1. Don’t start; don’t even think of using this method, if you will find irregular bleeding to be a problem. Every woman’s periods change if she uses Depo Provera.
  2. If you experience weight gain on Depo you just have two options: eat less and exercise more – just as it is for every other person trying to lose weight.
  3. Depo has the highest discontinuation rates of any contraceptive. If you decide to stop using Depo, start your next method before your Depo becomes ineffective.
  4. Each time you get a shot, write down on your calendar the date of your next injection.

Condoms for men: Background INFO:

Over half the time a person infected with HIV, herpes, hepatitis, human papilloma virus (HPV) or Chlamydia has no symptoms.

Dual protection with a condom and one of the LARC methods (an IUD or an implant) provides excellent protection against pregnancy, infection and infertility.

When condoms of different sizes are available they will make sex using a condom more comfortable for many men.

Most important suggestions:

  1. Condom use should be negotiated in advance. Commitment to using condoms every single time by both partners is the first step to excellent use of condoms
  2. For a condom to be used it must obviously be available
  3. If the woman puts the condom on for the man this may overcome much of the man’s resistance to condom use. 
  4. The condom should be placed onto the penis before any genital contact.
  5. While the penis is still erect it penis should be removed from the vagina immediately after ejaculation occurs, holding the rim or the condom and.
  6. Two condoms should be used at once when a couple has experienced more than one condom break
  7. Clinics hoping to increase condom use should provide a 6 to 12 month supply of condoms at each visit.  Men and women buying condoms should buy enough to cover them for 6 to 12 months (no pun intended!).

Robert A. Hatcher MD, MPH
Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, Georgia