Between 2001 and 2008, there were 2.34 million unintended pregnancies (66%) among single women in their twenties. Married women in the same age group had a lower rate of 31%. Unintended pregnancy is a pregnancy that was mistimed, unplanned, or unwanted at time of conception. With the availability of highly effective contraceptive methods, it is unfortunate that women continue to have unintended pregnancies. Unintended pregnancies can impose health risks to the mother and to the infant, as well as financial burden. In 2012, the Department of Agriculture released a study revealing that it will cost $241,080 to raise a child in the United States from birth to age 17. The methods of contraception range from abstinence to sterilization. This article will focus on prescription medications and surgical options. Please note: none of these options will protect you from sexually transmitted diseases.
How many kids do you want?
Before deciding on which contraceptive method you will use, it is best to discuss with your spouse or partner about family planning. How many kids do you want? When shall you start? What is the desired age gap if multiple children are considered? Once you have agreed on the above questions, continue to the next section.
Are you compliant?
Be honest. Do you forget to take your daily vitamins? Don’t worry; most patients do forget to take their medication. In the case of birth control pills, being forgetful may be costly and you might be unexpectedly expecting. In 2008, the Society of Obstetricians and Gynecologists of Canada issued recommendations on missed doses of oral contraceptives. Adhering to directions was crucial to avoid ovulation. Active pills should be started immediately after the hormone-free week. If active pills were not started on time or just one pill was missed during the first week of the dose pack, back-up methods (such as condoms) were recommended until 7 consecutive days of active pills were established. Back-up methods were also required if three or more pills were missed during the second or third week of the dose pack.
If you are compliant (take medications regularly), then you may consider daily birth control pills. The most popular and effective ones are combination oral birth control pills which contain low doses of estrogen and progesterone. When taken daily, the pills release hormones “tricking” your body not to release an egg that month. The progesterone hormone also creates a hostile environment for sperm, making fertilization difficult. The first 21 days of the pill pack are active (with hormones) while the last 7 days are placebo (no hormones). During the placebo pill week, your monthly menses will occur. Side effects such as nausea, breast tenderness, breakthrough bleeding, mood changes, and fatigue can be abated by switching to different formulations that offer higher or lower hormone doses or provide an overall lower hormone dose in two or three-phases (called bi-phasic or tri-phasic oral contraceptives, respectively).
There are also newer formulations called extended-cycle birth control pills. The combination pills are touted to reduce the number of menses by providing consecutive active pills for a longer duration (84 days). At the end of 84 days, the pack has 7 days of placebo pills (to allow for menses to occur). Instead of placebo pills, new products like Seasonique™ and LoSeasonique™ offer a week of low dose estrogen. The low dose estrogen pills prevents cramping, bloating, and headaches associated with menses and reduces duration of menses.
Progesterone-only pills (also known as “mini pills”) do not contain estrogen. They are less effective compared to combination oral contraceptives. However, this type of oral contraceptive is preferred for women who have risk factors for increased side effects from estrogens. These risk factors include:
Advantage: Oral combination birth control pills are considered highly cost-effective ($9 per month for generic versions and up to $30 for brand name pills or covered by insurance) with a very low failure rate (0.1%). There are a variety of available formulations with less unwanted side effects; can stop heavy menses or reduce the number of menses. They only provide short-term contraception so you can stop the medication if pregnancy is desired.
Disadvantage: Side effects include nausea, headaches, breast tenderness, breakthrough bleeding, irritability, weight gain, acne, hirsutism, increased appetite, and blood clots in the legs and lungs. Noncompliance can lead to an unintended pregnancy. Physicians reported that the most common reason for noncompliance was breakthrough bleeding.
Can you remember to put on a patch?
If you are honest and cannot take a pill daily, then the next option is to consider the Ortho-Evra patch™. The patch is similar to a combination oral birth control pill. Each patch contains low doses of estrogen and progesterone. The patch is replaced every week. The first three patches are active (with hormones) while the last patch is placebo (no hormones). Hence, during the last week with the placebo patch, you will have your usual menses.
Advantage: The patch provides short-term contraception (can be removed if pregnancy is desired), is applied to the upper arm area or back, and considered waterproof.
Disadvantage: The patch costs more than oral contraceptives ($132 per month; some insurance plans do not cover patches). The patch is not as effective in women who are 198 pounds or more, side effects can occur (same as combination birth control pills), and can cause skin irritation. If the patch is accidentally removed, efficacy may be reduced and back-up methods are required.
Can you insert a device once a month?
If you don’t like the idea of the weekly patch, do not worry. There are other options which require your effort once a month, every 3 months, every 3 years, every 5 years, or every 10 years. Unfortunately, the options become more invasive and in some cases, more costly.
The NuvaRing™ is a small flexible vaginal ring and contains low doses of estrogen and progesterone. The diameter of the ring is 4 mm. With the help of your physician, you will be taught how to insert and remove the ring once a month. On Day 1, you insert the ring. After 21 days, you remove and discard the ring. For the next 7 days, you will not have a vaginal ring. During this week, you will have your usual menses. After the 7 days, you will insert a new vaginal ring and repeat the cycle.
Advantage: It provides short-term contraception (can be removed if contraception is desired). It has a very low failure rate (less than 1%), making it very effective.
Disadvantage: There is a higher cost associated with the brand name contraceptive ($104 per month; some insurance plans may not cover the ring). The ring may be expelled out on its own (just reinsert the device), you and your partner may notice it during intercourse, and side effects can occur (same as combination birth control pills).
How about getting a shot every 3 months?
Although the vaginal ring has a simpler dosing regimen, you might not like the idea of inserting a vaginal ring inside yourself. The next option is an intramuscular hormone injection, called Depo-Provera™. Depo-Provera™ is given every 3 months and must be administered in a clinic (under supervision of a physician). The injection contains medroxyprogesterone and injected into the shoulder or gluteal muscle. It prevents pregnancy by inhibiting ovulation.
Depo-SubQ Provera™ is the same medication but given subcutaneously (under the skin) every 3 months. The site of injection is either the thigh or abdomen.
Advantage: These injections have a very low failure rate of 0.3%, making them highly effective. The progesterone-only injections are ideal for those who cannot tolerate estrogen. They also have fewer side effects compared to combination contraceptives but may cause breakthrough bleeding. Menses may be absent or infrequent. Overall, the injections are considered low maintenance.
Disadvantage: You will need to schedule doctor’s appointments every 3 months for the injection. Heavy and irregular flow after the first injection is common. Breakthrough bleeding also is common. Depo-Provera™ has been shown to decrease bone mineral density with long term use (> 5 years). However, studies have shown that the side effect was reversible upon cessation of the injections.
I am certain that I do not want kids in the next 3 years. What are my options?
Taking a pill every day for the next 3 years seems daunting. Going to the doctor to get a shot every 3 months for 3 years sounds painful. There are two viable options: Skyla™ and Nexplanon™.
Skyla™ is an intrauterine device (IUD) that is inserted by a physician and lasts for 3 years. After 24 days from insertion, Skyla™ releases levonorgestrel at a rate of 14 mcg per day. After 3 years, the daily dose diminishes to 5 mcg per day. In the first 3 to 6 months, you might notice heavier bleeding and spotting. Over time, menses may be lighter and irregular. Once Skyla™ is removed, menses will return to normal.
Another option is called Nexplanon™, a hormonal implant. Nexplanon™ is inserted by a physician, underneath the inner skin of the non-dominant arm. It contains a different type of progesterone called etonogestrel and is released at a constant daily rate.
Advantage: Both forms are highly effective (99% effective).
Disadvantage: During insertion, uterine perforation can occur with Skyla™. It can also be expelled on its own (need to discard and have the doctor insert a new one). Removal may be difficult and painful as scaring can occur. To insert Nexplanon™, a small incision is needed. You should be able to feel the implant under the skin. Since Skyla™ and Nexplanon™ contain only progesterone-only, breakthrough bleeding is the most common side effect.
I want a longer duration of contraception of 5 years. What are my options?
Mirena™ is another IUD, which contains levonorgestrel. Instead of 3 years, the device lasts for 5 years.
Advantage: It is cost-effective ($800 for one device but lasts for 5 years) with a low 0.1% failure rate. In studies, twenty percent of women have reported absence of menses.
Disadvantage: Breakthrough bleeding is a common side effect. During insertion, uterine perforation can occur. Mirena™ can be expelled on its own (need to discard and have the doctor insert a new one). Removal may be difficult and painful as scaring can occur.
I am certain that I do not want kids in the next 10 years. What are my options?
For long-term contraception, you might want to consider having a Copper T380 inserted. The Copper T380 is an intrauterine device (IUD), similar to Skyla™ and Mirena™. The major differences are that it does not contain hormones and lasts up to 10 years.
Advantage: It is highly effective (99.4% effective). Since there are no hormones, the Copper T380 is ideal for those with other medical conditions.
Disadvantage: Since the Copper T380 does not contain any hormones, it will not help those patients with a history of menorrhagia or dysmenorrhea. The risk of uterine perforation or complications with insertion is much higher among women without a history of vaginal deliveries.
I am certain that I do not want to become pregnant ever again. What are my options?
The decision to not bear any more children is difficult but sometimes, it is appropriate. Your family has grown to the perfect size or perhaps, you are older and becoming pregnant may post a health risk to you and to the baby. There are two options: bilateral tubal ligation and Essure™.
Bilateral tubal ligation (BTL) is a surgical procedure where the physician blocks the fallopian tubes. After the physician makes a small incision on the abdomen (near the navel), he/she will insert a laparoscope to place clips, rings, or sutures in the fallopian tubes. By blocking the tubes, eggs are still released from the ovaries but cannot reach the uterus, where fertilization occurs if sperm is present. This form of sterilization is costly as it is considered an outpatient surgical procedure. After the short procedure, the patient is sent home on the same day. Recovery time can last as little as 1 day or up to 4 days.
Similar to the BTL, Essure™ is a short outpatient procedure. Generally, the patient is placed under conscious sedation in the office. During the procedure, a camera (hysteroscope) is introduced into the uterine cavity through the cervix and metal coils are inserted into the tubal ostia. There are no abdominal incisions needed. To ensure that the metal coils have successfully blocked the tubes, you will need a hysterosalpingogram (X-ray of the uterine cavity and fallopian tubes) after three months.
Advantage: They are the most effective forms of contraception. Essure™ is a great option for overweight or obese patients. BTL is a surgical option that can be done shortly after delivery (vaginal or Caesarean) during the same hospital admission.
Disadvantage: With any procedure, time is needed to recover. Pain and discomfort are expected shortly after the procedures. BTL is not the safest choice for overweight or obese patients. Permanent sterilization (with BTL or Essure™) is difficult to reverse; they are not recommended in patients younger than 30 years old.
Does medical insurance cover contraception methods?
Yes, however, there are many requirements and restrictions. For example, medical insurance will cover the prescription cost of generic oral contraceptives but you have to pay the copay each time you refill. Insurance will also pay for the prescription provided that you used it according to the instructions. If you refill the prescription too soon (usually 5 days or more before its due), then insurance will not cover the cost. In some cases, insurance plans will not cover vaginal rings or patches unless the patient has failed contraceptive methods on formulary (for example, oral combination pills).
Insurance will partially pay for devices (IUDs and copper T380) and surgeries after you reached your annual deductible. For example, if your deductible is $2,000 and the cost of Mirena™ is $800, you will need to pay the full cost of the IUD. Even if you reached your deductible, insurance will only cover 20% to 40% of the cost depending on your plan. It is imperative that you confirm with your medical insurance about its coverage.
As sexually active adults, you have the privilege and right to seek your own contraception method. As women, you have the added privilege of bearing children if you choose to. If the pregnancy is unintentional, the privilege unfortunately becomes more of a duty and a source of financial burden and stress. Consider all your options. If you are sexually active and pre-menopausal, discuss with your spouse or partner and select a viable contraception method. Without contraception, you might just be a heartbeat away from a positive pregnancy test.
About the Author
Dr. Karine Wong has a 10 year history of working in hospital management and 2 years as a hospital pharmacist and outpatient pharmacist. She recently published a children's book called Don't Sit On Her.
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