Contraception: which option suits you best?
From IUD’s to the morning-after pill ... Dr. Jireh Serfontein, sexual health physician, offers her advice on different forms of birth control and their effectiveness, advantages and disadvantages.
Sensitive content: the female reproductive system and contraception are discussed from a medical viewpoint.
“When I speak to a patient about contraception, the consultation can easily take half an hour because of the many options available in South Africa,” says dr. Jireh Serfontein, general practitioner from Pretoria working exclusively in the field of sexual health. “I usually explain that contraception can be divided into hormonal and non hormonal categories and discuss the possibilities in each category. This makes it easier to get a grip on the many options and their upside and downside.
“Hormonal forms of birth control involve either combined hormonal contraceptives – the pill, patch or vaginal ring – which contain both estrogen and progesterone, or the progesterone-only pill, implant or injection.
“The only real non hormonal contraception besides condoms and natural methods is the copper IUD. The Mirena and the Kyleena are intra uterine systems (IUS), and although it contains the hormone progesterone, the systemic absorption is minimal.”
“I tell my patients that all forms of contraception provide protection against falling pregnant. Of course, some are more effective than others. But what I really like to focus on is the extra advantages a specific choice might afford a specific patient.”
Hormonal forms of contraception: combined hormones
The pill
“Most women are familiar with the pill, which is a combined birth control option. Here’s how it works: the hormones come from outside, your body picks them up, decides that there are enough hormones and sends a message to your ovaries which puts them ‘to sleep’. This suppresses ovulation. If no egg is released, it is impossible to fall pregnant.
“The pill comes in many combinations. The difference usually lies in the type of progesterone and the amount of estrogen. When doctors talk about a stronger or lighter pill, they are referring to the amount of estrogen it contains.
“One takes ‘active’ pills for three weeks and placebo pills for one week. The withdrawal of hormones allows menstrual bleeding to occur.” (Whether menstrual bleeding really needs to take place, is discussed further on in the article).
“One advantage of the pill is that is protects the ovaries in the long term and reduces the risk for cysts.
“A big disadvantage, however, is that up to 70% of women who use it experience side-effects. They may report changes in mood, feel more emotional, experience headaches, and PMS symptoms or migraines may be worse than before. The pill can impact on sexual relations by causing low libido, difficulty in reaching orgasm, or vaginal dryness which can result in painful intercourse. Having effective contraception in place is no use if you never feel like having sex!
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“Although the pill can improve skin conditions such as acne, a girl who is not sexually active and takes the pill may come to experience low libido or other sexually related problems later, when she does become sexually active. In that case, she may never attribute these problems to the pill. In my view, there are other ways of managing skin problems. It need not be done at the cost of sexual function.”
How effectively does the pill prevent pregnancy?
“When starting to take the pill, protection will only kick in after seven days. If a woman takes the pill at exactly the same time each and every day, it should be 95% effective. However, skipping a day, taking the pill at different times on different days, taking antibiotics or vomiting when you are ill could all affect the efficacy of the pill. Life happens, and for most women it would mean the pill is only 85-90% reliable in terms of preventing pregnancy.
“Extra protection is necessary during illness or when taking antibiotics. In the case of antibiotics, ‘extra protection’ means refraining from sex up to seven days after completing the course of antibiotics or using condoms. Condoms should always fit well! And remember to leave a little space at the top, otherwise it can break.”
The patch
“Like the pill, the patch suppresses ovulation. A patch is placed on your skin once a week for three weeks, and then you skip one week, allowing menstrual bleeding to occur.”
Vaginal ring
“The vaginal ring is placed into the vagina once a month - no need to go to the doctor, you can do it yourself. It releases the same type of hormones as the pill and the patch and suppresses ovulation. During the fourth week, you take it out.”
Vind uit hoekom Jireh gaande is oor die veld van seksuele gesondheid.
Advantages of combined hormonal forms of birth control:
“They will regulate your period. It is a good choice for the woman who experiences irregular periods and prefers them to be predictable. Menstruation also tends to be lighter and less painful, breast tenderness is reduced and PMS can be more manageable.”
Should menstruation take place?
“There are no medical reasons why we should menstruate each month. Many women worry about ‘where the blood goes’ when one doesn’t. I tell them the only reason you have your period is because there is a withdrawal of hormones since you did not fall pregnant.
The lining of the uterus is built up in anticipation of pregnancy, and when it doesn’t happen, the lining breaks down and is shed: that constitutes your period. If you don’t menstruate, the lining will stabilise of its own accord.
“Personally, I feel there are advantages when you don’t menstruate: it involves less discomfort, we see less iron deficiency, and because the ovaries are ‘asleep’, we see a smaller incidence of ovarian cancer; also of endometrial cancer.”
Could combined hormonal contraceptive options really make one put on weight?
“This has not been scientifically proven, but people differ. Some of my patients have reported weight gain and subsequently found it easier to lose weight when they changed to another form of contraception. The pill contains no calories, but it can stimulate your appetite. If you eat more, it follows that you could gain weight.”
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Do combination contraceptives affect fertility?
“Generally, a woman’s ovaries should start functioning and return to ovulation within 28 days, no matter how long she has been on one of the combined hormonal contraceptives. It is not true that remaining on the pill for years would harm your chances to fall pregnant, or that you need to stop taking the pill a long time before planning to get pregnant. If you do fall pregnant, it shows that your body is ready for pregnancy.”
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Hormonal forms of contraception: progesterone-only
The pill
“The ‘mini-pill’ is often used after pregnancy since it has the smallest effect on the production of breast milk. It is also suitable for women who don’t do well on estrogen. On the other hand, it is less reliable than other forms of birth control.”
The implant
“Progesterone implants are more or less the size of a matchstick and placed under the skin in your upper arm. It releases progesterone into your bloodstream and remains there for three years.”
The injection
“Women can get a progesterone injection which lasts two to three months. One disadvantage is that women who use this may gain weight – from all the options available, the injection is the one that most often leads to this complaint.”
Non hormomal forms of contraception
Mirena and Kyleena
“I call intra-uterine devices or IUD’s - the Mirena, Kyleena, and copper IUD – non-hormonal options because, although the Mirena and Kyleena do release hormones, the hormones have minimal systemic effects and mainly works inside the uterus. The copper IUD is hormone-free.
“Generally speaking, IUD’s are the most reliable form of contraception, comparable to sterilisation.
“The Mirena and Kyleena are well-known. The Kyleena is smaller than the Mirena and suitable for women who have not given birth and have a smaller uterus. It releases fewer hormones.
“Both these IUD’s are inserted into the uterus, where they release a type of progesterone which thins the lining of the womb and partially suppresses ovulation. Also, when the lining remains thin, implantation cannot take place after a sperm and egg have met. This prevents pregnancy. Moreover, the mucus in the cervix thickens, which prevents sperm from penetrating.
“The Mirena and Kyleena provide reliable birth control protection for up to five years. At the end of this period – not to the day, but more or less - the hormones start fluctuating and protection may wear off. It is advisable to replace the Mirena or Kyleena after five years for safety’s sake.”
How are the Mirena and Kyleena inserted?
“The device is a T-shaped plastic frame that's inserted into the uterus by a doctor. Some doctors prefer to do it in a theatre under anaesthesia, but I usually insert it in my consulting rooms. The patient lies on the bed and, as in the case of a pap smear, a speculum is put into vagina. It opens up the vagina so I am able to see the lower part of the uterus called the cervix. In it there is a small gap leading into the uterus. The IUD, encapsuled in a plastic sheath, is inserted through this gap into the top part of the uterus and released from the sheath. Once inserted, the top arms of the T unfold to fit nicely and keep the device in place.
“The procedure does hurt, but I always tell my patients it’s over in seconds. The preparation takes a while, but the insertion itself happens very fast. Usually I hear a very loud ‘ouch!’ but the intense pain lasts less than a minute. Of course, childbirth is much more painful.
“The pain experienced after insertion is comparable to menstrual pain. It can come and go. It usually vanishes completely after a period of six weeks to six months, as does spotting, if it occurs. There is, however, a percentage of women who may go on experiencing cramps or discomfort from time to time.
“Women who still have their periods on the Mirena or Kyleena can have irregular periods. The reason for this is that the lining of the uterus experiences irritation, like a scab which is torn off and causes bleeding. Eventually, spotting should decrease.”
More advantages:
“IUD’s do not affect breast milk production. Due to the thinning of the lining of the uterus, many women will not menstruate at all. With the Mirena, up to 80% may stop menstruating; with the Kyleena, it is closer to 25%. This is a big advantage for women who have heavy and painful periods. In fact, inserting an IUD is one of the ways in which we treat heavy periods. Those women who keep on having their periods, may find that they are lighter.
“These IUD’s reduce the chance of developing endometrial cancer. They also have no adverse effect on long term fertility.”
Copper IUD
“The copper IUD I use, the Nova-T, has been with us for a long time. It is inserted into the uterus like the Mirena. It is completely hormone-free. It releases small amounts of copper into the uterus, which influence the uterine environment so that sperm cannot survive. It provides protection for five years.
“A while ago, a variation called the copper pearls was released. Several copper pearls are strung onto a uterus-friendly frame. It looks different to the Nova-T but works on the same principle.”
Can the release of copper in your womb have an adverse effect?
“Only if you have a copper allergy. Recently, one of my patients developed a severe itch and skin rash after having the copper IUD inserted. We did a blood test which confirmed the allergy. We removed the IUD.”
Further advantages and disadvantages:
“The copper IUD is cheaper than the Mirena or Kyleena. It is a good option for women who either fear the use of hormones or are overly sensitive to them.
“Some women who use the copper IUD experience heavier and/or more painful periods.”
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The morning-after pill
“Should you have a teenage daughter who does not have any contraceptive measure in place, and she comes to you and says she has had sexual intercourse, don’t fight with her. Go to the pharmacy, get her the morning-after pill (for which you need no prescription) and rather prevent an unwanted pregnancy.
“The morning-after pill can be taken up to 72 hours after intercourse, but the sooner it is taken, the better. It is not 100% reliable.
“Remember that sex education, when done properly, will delay children’s sexual debut. Children who have more information and understand the risks involved will make wiser decisions. Create a safe space where your child can speak to you. If a teenager needs the morning-after pill at regular intervals, another form of contraception should be considered.”
Follow-up with a medical expert is important
“No matter which form of contraception you choose, you should follow up with your practitioner. I see a patient six weeks after she has started on any form of contraception. Should she experience any changes – health-wise, regarding her sexual relations, or her mental well-being – a woman should consult her practitioner. Problems which may seem completely unrelated could be caused by the form of contraception that you chose. Never settle for less or think things will get better when you are experiencing problems. Sexual problems tend to become relationship problems. The choice of contraception should be talked through with a practitioner who is comfortable discussing intimate matters.”
Contact detail:
Dr. Jireh Serfontein is a general practitioner from Pretoria who works exclusively in the field of sexual medicine. She is part of the team at My Sexual Health with offices in Pretoria, Johannesburg and Cape Town.
Tel: 012 816 8240
Email: admin@mysexualhealth.co.za
Websites: https://mysexualhealth.co.za/ and http://drjirehserfontein.co.za/
This article has been based on an Afrikaans podcast interview which aired on rrRADIO, the podcast channel of rooi rose.
Images Unsplash. Models used.