The fact that there are so many forms of contraception means that there is no one ideal contraception that suits all women (no one size fits all solution). Women have many reasons for seeking contraception and their final preference depends on:
- the stage of their reproductive cycle
- medical factor,
- social factor,
- economic factor,
- religious factor.
One way to decide is whether they are seeking a permanent contraceptive solution (tubal ligation) or whether they prefer a reversible form of contraception. For reversible contraception, they have to decide if it is for short term (months to years) like:
- condoms,
- oral contraceptive pills
- injectables.
Meanwhile, they may prefer long term reversible (3-5 years) like:
- Implanon,
- copper IUCD
- Mirena IUS.
There are many types of contraception available worldwide but these are the ones that are available in Singapore.
Non-hormonal (short term)
1. Condom
A male condom is a sheath worn over the penis. When a man climaxes, the male condoms are able to trap the sperms [1]. Hence, it may reduce the chances of pregnancy wear used. Apart from that, it is able to provide some protection against sexually-transmitted infections (STIs). An example would be HIV [2]. Therefore, it is an excellent method for young couples or for people with multiple sexual partners.
A male condom is about 99% effective only when it is used in the proper way. In other words, only 2 in every 100 women would get pregnant in a year [3]. This is more effective than several other standalone forms of contraception such as withdrawal or using spermicides (chemicals). The female may get pregnant when:
- condom was not put on before the intercourse,
- condom splits,
- oil-based lubricant was used together with a condom - Vaseline, creams or lotions
The oil-based lubricant may make holes in the latex condom [4]. Many of the males have complained that the condom does dull their pleasure during intercourse. Hence, affecting their orgasm and are not so keen on this method of contraception. Apart from that, some allergies to condoms have been reported. However, it is rare [5]. Condoms are easily accessible and can be gotten off the shelf; it does not require a doctor's prescription.
2. Femidom
The female condom (Femidom) was invented more than 20 years ago. It looks like a tiny plastic bin liner. There is a ring round the opening and another one at the closed end - which is the end that goes into the top of the vagina.
Unlike the male condom, it is made out of polyurethane. Hence, it is very likely to cause any allergies [6]. Besides that, it will not get damaged by oil-based lubricants [7]. The female condom is effective provided that it is inserted into the vagina correctly. Also, it is provided that the man doesn't put his penis outside it.
It is over 95% effective [8]. Before sex, the woman or the partner puts the female condom inside her vagina. Couples are not protected if you only put it in halfway through sex. With that, there is a risk of getting pregnant. Many people don't realise sperm can be present in the man's pre-ejaculate fluid, which he secretes as he gets sexually excited [9]. In other words, the condom has to be placed before intercourse.
Your fingernails or jewellery may cause the condom to tear. Thus, care must be taken [10]. Although the femidom is still nowhere near as popular as the male's, some couples do prefer it. Some women are keen on the idea that it lets them control their own fertility especially if the male partner refuses to wear a male condom. In addition, they do provide some protection against STIs just like the male condom [11]. As both condoms are to be used before sex, it does make the couple feel distracted from the spontaneous act of intercourse.
Advantages:
Disadvantages:
Very effective
Easily available (male condoms)
Only need to use them when you have sex
Help to protect against some sexually transmitted infections (STIs), including HIV
Male condoms come in many different varieties, shapes and sizes
Female condoms can be put in at any time before sex
Can interrupt sex
Male condoms can slip off or split if used incorrectly
When using the female condom care is needed to ensure the penis goes inside the condom and not down the side of the condom and the vagina
Some people are sensitive to the chemicals in latex condoms, although this is not common
Oil-based lubricants, such as body oils or lotions, should not be used with latex condoms
Hormonal (short term)
1. Oral Contraceptive Pill (OCP)
The OCP is a tablet that contains 2 female-type hormones: an oestrogen and a progestogen. Various different oestrogens and progestogens are used in the many different types of pill which are available [12]. Thes 2 hormones cause the ovaries to stop producing an egg each month. When this happens, females won't get pregnant. The hormones thicken the secretions around the cervix. Hence, it is harder for sperms to get through. This pill makes the lining of the womb to be thinner.
It is an effective method and that many females rely on this. When it is taken exactly as prescribed, it is highly effective [13] In fact, the pill is just about the most effective method of contraception there is, apart from sterilisation.
Each pack contains 21 pills. It is to be taken once every day for 3 weeks. After the 3 weeks, there is a week ‘break’. During those seven days, the menses occurs. After the week’s break, women start on the next packet. So it’s ‘three weeks on and one week off’ throughout the year [14].
It is now the practice to take the first-ever pill on the expected first day of the menses. With that, the female will be protected immediately. Other pill regimes contain 28 tablets to be taken daily without a pill-free break. This improves compliance and reduces pill failure [15].
However, there are possible rare serious side-effects to this pill. They may include:
- Raised blood pressure
- A very small number of women may develop a blood clot which can block a vein (venous thrombosis) or an artery (arterial thrombosis, heart attack or stroke)
- A small increase in the risk of being diagnosed with breast cancer
- A small increase in the risk of cervical cancer if the pill is used continuously for more than five years
The pill may not be suitable for all women, but for most women, the benefits of the pill outweigh the possible risks. The pill may be unsuitable if:
- women might already be pregnant
- Smoke and are over 35, or are over 35 and stopped smoking less than a year ago
- Are very overweight
- Take certain medicines
- Have had a previous thrombosis
- Have a heart abnormality, circulatory disease or high blood pressure
- Have very severe migraines or migraines with aura
- Have breast cancer now or within the last five years
- Have active liver or gall bladder disease
- Have diabetes with complications, or have had diabetes for more than 20 years
Advantages:
Disadvantages:
- Doesn’t interrupt sex
- Usually makes menses regular, lighter and less painful
- May help with premenstrual symptoms
- Reduces the risk of cancer of the ovary, womb and colon
- Reduces acne in some women
- May protect against pelvic inflammatory disease
- May reduce the risk of fibroids, ovarian cysts and (non-cancerous) breast disease
Temporary side-effects at first may include:
- Headaches, nausea, breast tenderness and mood changes
- Breakthrough bleeding (unexpected bleeding on pill-taking days) and spotting
2. Depo-Provera
Depo-provera (medroxyprogesterone) contains a type of hormone called a ‘progestogen’ [16]. It is injected into the muscle which stops women from ovulating (producing eggs). It is usually injected in the buttock, leg or arm. This hormone thickens the mucus in the cervix thus, making it difficult for sperms to get through.
They make the lining of the womb thinner so that if an egg (ovum) became fertilised, it would have difficulty attaching itself to the lining. Each injection lasts for 3 months [17]. It is around 99% effective. The injection can be started up to and including the fifth day of your period. If started at any other time, additional contraception has to be used for 7 days.
There is a chance that the period will be disrupted in some way. With that, the common side effects are:
- heavy periods (menorrhagia)
- prolonged periods
- irregular or infrequent periods (oligomenorrhoea)
- absent periods – though many women are very grateful for this effect
- headache
- tummy ache
- weakness
- dizziness
- weight gain
- delayed return of fertility after stopping the jab
Most women can have contraception injection, but it may be unsuitable if:
- already pregnant
- Want a baby within the next year
- Don't want periods to change
- Have thrombosis, heart or circulatory disease
- Have active liver disease
- Have breast cancer now or within the past five years
- Have migraines with aura
- Have diabetes with complications or have had diabetes for more than 20 years
- Have risk factors for osteoporosis
Advantages:
Disadvantages:
Very effective
Doesn’t interrupt sex
Suitable for women that cannot use estrogens or are breastfeeding
May reduce heavy painful periods and help with premenstrual symptoms for some women
May give some protection against cancer of the womb
May give some protection against pelvic inflammatory disease
Not affected by other medicines
periods may change in a way that is not acceptable or they may stop
Irregular bleeding may continue for some months after stopping the injection
may have weight gain
Some women report having headaches, acne, mood changes and breast tenderness
The injection lasts for 12 weeks, so if women have side-effects they will continue during this time and for some time afterwards
periods and normal fertility may take some time to return - more than a year for some women
Non-hormonal (long term)
1. Copper IUCD - an intrauterine contraceptive device
Most IUDs are now T-shaped. They’re made of plastic and copper. All IUCDs has a little thread, which hangs down a short distance into the vagina. These are useful for checking that the device is still in place and are used when it’s time to remove the IUCD [18].
It prevents sperms from getting through the womb and into the tubes. They alter the secretions (mucus) in the cervix, thus creating a further barrier for sperms and affect the womb lining. It makes it less likely to ‘accept’ an egg. The IUCD does not work by ‘causing an abortion' [19]. IUCDs are almost 99% effective [20].
But, IUCDs can make periods [21]:
- heavier,
- last longer,
- more painful.
IUCDs are not usually the best choice of contraception for women who already have heavy or prolonged periods [22]. They might well do better with another the pill or the IUS. Most women can use them, but not all. An IUCD is not recommended if:
- There is a structural abnormality of the womb or cervix.
- There is a pelvic infection, for instance, a sexually transmitted disease (STD).
- There is unexplained vaginal bleeding.
- women have heart valve problems
- there is an allergy to copper (which is rare).
- previously had an ectopic pregnancy.
- already pregnant.
IUCDs are great for those who already had a pregnancy. This is partly because the cervix is generally wider, making the insertion of the device easier and less painful. IUCDs last from 5 years before they need to be changed [23].
Advantages:
Disadvantages:
It works as soon as it is put in
It works for 3 to 5 years depending on type
It doesn’t interrupt sex
It can be used if breastfeeding
normal fertility returns as soon as the IUCD is removed
It's not affected by other medicines
periods may be longer, heavier or more painful - this may improve after a few months
need an internal examination to check if it's suitable, and when it is fitted
There is a very small chance of infection in the first 20 days after the IUD is put in
The IUCD may come out (expulsion) or it may move (displacement) - this is more likely to happen shortly after it has been put in
The IUD may go through (perforate) the cervix or womb when it's put in, but the risk is low when it's put in by an experienced doctor
If women become pregnant, there is a small increased risk of having an ectopic pregnancy (a pregnancy occurring outside the womb, normally in the fallopian tube). This risk is less than in women using no contraception
Hormonal (long term)
1. IUS (Mirena)- intrauterine system
The IUS is quite different from the IUCD although it may look similar because it contains a hormone. In addition to being a contraceptive, it actually ‘treats’ period. Periods will be shorter, lighter and less painful. Often, the doctor do recommend this method in order to treat period problems [24].
Similar to the IUCD, it is T-shaped and inserted into the womb. It has a couple of short threads hanging from the foot of the ‘T.’ These are useful when removing it. The stem of the ‘T’ contains a reservoir full of female hormone. It is known as a ‘progestogen.’ (levonorgestrel). This hormone is steadily released into the womb, day after day [25]. It can last for up to five years [26].
In fact, it is very effective – and maybe better than the IUD [27]. Its effectiveness rate is generally around 99%. It works by making the lining of the womb thinner, so it's less likely to accept a fertilised egg. It thickens the mucus in the cervix, making it more difficult for sperm to reach an egg. Apart from that, it may stop the ovaries releasing an egg (ovulation). Most women are suitable, but it may be unsuitable if:
- already pregnant
- Have cancer of the womb or ovary
- Have breast cancer now or within the past five years
- Have any other problem with the womb or cervix
- Have an untreated sexually transmitted infection or pelvic infection
- Have migraines with aura
- Have active liver disease
- Currently have thrombosis, heart or circulatory disease
- Have unexplained bleeding from the vagina (for example, between periods or after sex)
Advantages:
Disadvantages:
It works for five years
It doesn’t interrupt sex
periods usually become much lighter, shorter and less painful, and they may stop completely after the first year of use, so the IUS is helpful if women have heavy, painful periods
It can be used if breastfeeding
normal fertility returns as soon as the IUS is removed
It can be used by women who cannot use estrogens
It's not affected by other medicines
Some women get acne
Some women report mood changes, headaches or breast tenderness
Some women develop small fluid-filled cysts on their ovaries - these aren't dangerous and don't usually need treatment
There's a very small chance of infection in the first 20 days after the IUS has been put in
It may move or come out (displacement), but this is most likely to happen shortly after it has been put in
The IUS may go through the cervix or womb (perforate) when it is put in
If women become pregnant, there's a small increased risk of having an ectopic pregnancy (a pregnancy occurring outside the womb, normally in the fallopian tube), but this risk is less than in women using no contraception
2. Implanon
Implanon is about the size of a thin matchstick. It contains a hormone called etonorgestrel. Most users have it inserted under the skin of their upper arm, not far above the elbow. The ‘match’ can easily be felt. But fret not, it’s not very visible unless someone who is looking for it. There will be a tiny scar at the point where the device was inserted however, it shouldn’t be very visible either [28].
Because of the local anaesthetic, the patient will feel minimal pain. Implanon is inserted during the first five days after the start of the period so as to ensure that the woman is not pregnant.
Implanon will run out of its hormone after 3 years. It releases a steady stream of a female-type hormone into the bloodstream [29]. The hormone will reach the ovaries and prevents them from releasing eggs. It will cause some minor anti-conception changes in the womb lining and in the cervix. This contraception method requires a properly trained doctor to perform insertion and removal. It is at least 99% effective [30].
Most women who want to use an implant can have one fitted. But it may be unsuitable if:
- already pregnant
- Do not want periods to change
- Take certain medicines
- Have active liver disease
- Have breast cancer now or within the past five years
- Have thrombosis, heart or circulatory disease
- Have migraines with aura
There are possible rare side-effects and that includes:
- headache
- spotting
- weight gain
- breast tenderness
- dizziness
- depression
Advantages:
Disadvantages:
Very effective
Doesn’t interrupt sex
Works for three years
Can be used by women who cannot use estrogens or who are breastfeeding
normal fertility returns as soon as it's removed
May give some protection against cancer of the womb
Offers some protection against pelvic inflammatory disease
May reduce heavy, painful periods
Periods may become irregular, longer or stop
Acne may occur
Some women report mood changes and breast tenderness
Requires a small procedure to fit and remove it and has to be performed by a trained doctor
All in all
As there are so many choices of contraception available today, this is why it is best for women to seek a detailed consultation with their gynaecologist. The specialist will be in a better position to recommend the most appropriate form of contraception that would best suit the woman's individual needs.
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