Family Planning Medical Population Public Health Women's Issues

Know About Contraception

If you need contraception, use it; if you don’t, be a source of information for other people. For many people, particularly teens, abstinence is the ideal contraception. Since contraception is the best way of decreasing the need for abortion, most people agree that good contraceptive services are beneficial.
We have come a long way in the eighty years since Margaret Sanger started the first family planning clinic in this country. Contraception is legal, we have much more effective methods, and contraception is available from many sources. You don’t have to go to a special clinic any more. Furthermore, people talk about family planning more freely. Do you remember when “rubber” was a dirty word?
There is room for improvement, however. We need new, better methods of family planning. How about a pill for men, for instance? We especially need methods that protect against sexually transmitted diseases (such as AIDS) as well as prevent pregnancy. Most of all, we need less irresponsible sex, both in real life and in the media. In the average year of watching TV an adolescent is exposed to over 12,000 sexual encounters, but only 1 percent mention contraception. Abstinence is still the best way to avoid pregnancy for most teens.
For specific questions about birth control, you should contact your health care provider. The most authoritative source of information on contraception is Contraceptive Technology (Irvington Publishers, New York). My favorite web site is; look under “Health Info”.
Unfortunately, there are many misconceptions about contraceptive methods. For instance, some people are afraid to take birth control pills because they think that “the pill” causes cancer. The truth is that birth control pills protect against cancer of the uterus and of the ovary. They also help prevent anemia, ovarian cysts, breast lumps, menstrual cramps and pelvic inflammatory disease. Although they do have some serious side effects, these are amazingly rare with the newer, low dose pills.
The same hormones as in “the pill” also offer protection against pregnancy if a woman takes them after unprotected intercourse. Called emergency contraception pills (ECP’s) or “the morning after pill”, this is one of the best-kept medical secrets. ECP’s are indicated in cases of rape, a condom failure or if a couple fails to use contraception. ECP’s can reduce the proportion of unplanned pregnancies in the USA.
Innovative means of delivering hormonal contraception are available. Some women love the shot that lasts three months, Depo Povera, although it usually causes menstrual irregularity. It often eventually stops all bleeding, which many women like. There is also a monthly shot. Lunelle has the advantage of relatively normal periods. Using it means a trip to the office or clinic every month, but women appreciate its dependability.
Hormone patches have proven popular with menopausal women. Soon a contraceptive patch, Evra, will be available. Each Evra lasts seven days. The first is placed while the user is menstruating, then she replaces it at the end of a week. After the third, she goes patch-free for a week, during which her period will start.
The Nuvaring is a small ring placed in the woman’s vagina for three weeks. It is then removed, and during the week without the ring, her period will start. Neither man nor woman is aware of Nuvaring when it is in place. Both Evra and Nuvaring have been shown to be more effective than birth control pills, although women who cannot take hormones shouldn’t use them.
Barrier methods are designed to prevent sperm and egg from getting together. They include male and female condoms, diaphragm and cervical cap and several different forms of spermacides (foam, creams, gels and film). Some barrier methods are available without prescription, and some provide partial protection against sexually transmitted diseases.
Perhaps the most cost-effective means of family planning is the Intrauterine Device (IUD). Recent studies suggest that it is even safer than previously thought. There are two available in the U.S.A. The Paragard lasts for up to ten years and uses copper to be 99% effective in preventing pregnancy. Mirena is good for up to five years. It is filled with a hormone to make it 99.7% effective while decreasing menstrual bleeding and cramps. Either can be removed in case of problems of if the woman wishes to conceive.
Fortunately, there are many contraceptive methods that are effective, safe, and some even stop the transmission of disease. Hopefully the future will bring even better methods. We should all be well informed about family planning techniques.

© Richard Grossman MD, 2004

Durango Herald Medical Population Public Health

Pick Mirena

If you were designing a perfect family planning method, what characteristics should it have? Certainly, the method would be highly effective and safe. Probably it should be designed for women, since they are usually more interested than men in controlling fertility. It would be nice if the method also had some beneficial side effects such as making periods lighter and less painful. Fortunately such a method is now available!
I have known about Mirena® for several years. Doctors in other countries, who have many years’ experience with it, have raved about it. The FDA finally approved it for use in the United States in 2000. It is wonderful to have another option for American women. As effective as tubal ligation, it is temporary and can be removed easily if a woman wishes to conceive.
Mirena® is made out of soft plastic in the shape of a “T”. The stem is filled with levonorgestrel, a potent form of progesterone—the hormone of pregnancy. A tiny amount of the hormone passes continually through the plastic into the uterus. It contains enough to last five years. Fortunately, although the levonorgestrel has a direct effect on the uterine lining, very little gets into the woman’s blood stream. Most women have no generalized symptoms from the hormone.
But isn’t this an Intrauterine Device (IUD)? Aren’t IUDs dangerous? Well, one IUD—the Dalkon Shield—was a disaster. Many years ago it was rushed to market before they had sufficient time to test it well. It made women vulnerable to serious infections, and some became infertile from the Dalkon Shield.
Two IUDs are now available in the United States, and both are amazingly safe. A woman who is in a mutually monogamous relationship is the best candidate for an IUD. Furthermore, IUDs work best for women who have given birth, since pregnancy stretches the uterus a bit. A potential user should be well informed about IUDs, and she should learn how to check that it is in the proper position. The device must be inserted skillfully by a qualified doctor or nurse.
How does Mirena® function? The levonorgestrel makes it more effective than other IUDs. Because the hormone causes the uterine muscle to relax, it also decreases cramps. The hormone prevents pregnancy in at least two ways. The principal way that it works is that it makes cervical mucus thick and sticky so that sperm cannot pass through. It also thins out the lining of the uterus. If a sperm got past the inhospitable cervical mucus and an egg did get fertilized, it would be unlikely to implant. This thinning effect also makes bleeding lighter or stops it completely.
One way of looking at Mirena® is that it is a means of getting the hormone where it can work most effectively. Because the hormone is released inside the target organ, only a tiny amount is needed, and side effects are minimized. One advantage of any IUD is that the user is constantly protected against pregnancy without having to do anything on a regular basis.
Levonorgestrel can cause a few annoying side effects. Certain women complain of increased acne or headaches, and rarely they will have breast tenderness or nausea. Some women stop having periods entirely, which is normal for a Mirena® user, as long as the device is in place. Fortunately, it does not cause weight gain.
Mirena® is small and flexible, which makes it well tolerated even by women who haven’t had a baby. The other popular IUD, Paragard®, is a bit larger and stiffer. Although Paragard® lasts longer than Mirena®—ten years versus five—women do not tolerate it as well if they haven’t started their family yet. In fact, young, childless women have requested many of the Mirenas® that I have placed so far.
Mirena® is called an IntraUterine System (IUS). I think that this is a marketing ploy to distinguish it from other IUDs. It is also possible that the manufacturer is preparing to market it for other indications. In many countries it has been used to help women who suffer from excessive bleeding or bad menstrual cramps. In addition, it prevents abnormalities of the lining of the uterus (including cancer), especially in menopausal women on estrogen. Although the FDA hasn’t approved Mirena® by for noncontraceptive uses, women welcome it for help with these problems.
At last we have an IUD that has a very low failure rate, few side effects and many benefits. Mirena® has great potential to help women control their fertility and deal with other problems.
© Richard Grossman MD, 2005