Women today have a wide variety of birth control methods to choose from. From condoms to the contraceptive pill, from IUDs to diaphragms, every woman can find a type of birth control that they feel comfortable with. Yet, all this choice can make it difficult to decide just which form of contraception is the right one for you. By reading up on the tried and tested kinds of birth control, as well as newer contraceptives, you can get a better idea of what would be most suitable for you.

Because there are so many different methods of birth control, contraceptives are typically sorted into various categories. Contraceptive types include barrier methods, hormonal birth control, long-term contraceptives, and natural birth control. Although some contraceptive methods are inadequate, the majority of birth control options are effective. However, it is important to note that no form of contraception provides 100% protection against pregnancy. The only fool-proof way not to get pregnant is to abstain from sex completely.

Barrier methods of birth control work to prevent pregnancy by stopping sperm from coming into contact with an egg. Contraceptives that fall into this category include female condoms, diaphragms, cervical caps, the contraceptive sponge, and male condoms. Associated with few birth control side effects, these contraceptives are non-hormonal. Additionally, the male and female condoms are the only forms of birth control that offer any type of protection against STDs.

Hormonal contraceptives help prevent a pregnancy by using synthetic forms of naturally occurring hormones to prevent your body from ovulating. In some cases, the hormones may also work to thin the lining of the uterus and to thicken cervical mucus. Unfortunately, hormones can also produce some unpleasant side effects including decreased libido, causing some women to be turned off of these very effective birth control methods. Depo-Provera (the "birth control shot"), birth control pills, the birth control patch, the birth control ring, Implanon as well as some IUDs, such as the Mirena, are examples of hormonal contraceptives.

Forms of long-term birth control include tubal ligations, IUDs, and, for men, vasectomies. Both tubal ligations and vasectomies are meant as permanent birth control methods, although they can be reversed. Once an IUD is inserted by your health care professional, it can stay in place for anywhere from five to seven years.

Many women prefer to use natural, hormone free birth control. Known as Fertility Awareness Methods (FAM), this type of contraception relies upon periodic abstinence when a woman is fertile. FAM can involve charting your basal body temperature and/or menstrual cycle; noting the changes in your cervical mucus; and using the rhythm method or it's newest incarnation, the standard days method. Breastfeeding is also a very effective type of natural birth control known as the lactational amenorrhea method (LAM).

Mirena Intrauterine System (IUS)

The Mirena IUS is like many other types of Intrauterine Contraceptive Devices (IUCD's) in that it is fitted by a doctor and remains in the womb for a fixed amount of time, after which it must be changed. It is different, however, in that it is much more effective than usual IUCD's and avoids many of the side effects that put women off this choice of contraception.

In this article the abbreviation IUCD refers to this whole group of contraceptives, and the terms Mirena and IUS will be used interchangeably.

Most IUCD's make a woman's periods heavier, but the Mirena makes periods lighter than usual. Because of this, it is frequently used as a treatment for heavy periods, even in women who don't need contraception. As can be seen in the picture, it is made of a light, plastic, T-shaped frame with the stem of the 'T' a bit thicker than the rest. This stem contains a tiny storage system of a hormone called Levonorgestrel. This hormone is also used in contraceptive pills such as Eugynon, Logynon, Microgynon, Ovran 30, Ovranette and Trinordial. In the Mirena, however, a much lower dose is released than when you take the Pill (about 1/7th strength), and it goes directly to the lining of the womb, rather than through the blood stream where it may lead to the common progesterone-type side effects (see below).

How Effective is the Contraception?

If 1000 women used the Mirena IUS for a year, only one would fall pregnant. This compares with about 10 for the normal IUCD, 20 for the Pill and 10-15 for the injection (Depo Provera). This is comparable to the effectiveness of sterilisation.

Mirena acts as a contraceptive in two ways: it makes the mucus at the neck of the womb (the cervix) much thicker, preventing sperm from getting through and it also makes the lining of the womb extremely thin, stopping implantation. In some women it prevents egg release (ovulation).

As with all IUCD's, if it does fail, there is a higher risk of ectopic pregnancy (a pregnancy located outside the womb, usually in the tube). If you felt pregnant or had a positive pregnancy test, it is important to see your doctor to rule this out. Overall, however, compared to women not using any contraception, the risk of ectopic pregnancy is greatly reduced (around 2 per 10,000 women each year) because the IUS is such a good contraceptive.

If a pregnancy does occur with an IUCD, it is advisable to remove the contraceptive if possible - this reduces the risk of bleeding, infection and miscarriage. Because failure is so rare, there is little information available on the effects on an ongoing pregnancy with the Mirena still in place.

Fitting the Mirena IUS

Before it is inserted, the doctor will do an examination to make sure the womb is a normal size and there is nothing else unusual to find. If there is some discharge, swabs will be taken to rule out infection before it is placed. The IUS is inserted within a week of beginning a period - this helps to reduce the chance of expulsion and irregular bleeding (as the womb lining is already quite thin at this time). It may be inserted immediately after surgical termination of pregnancy, but should be deferred until 6 weeks after delivery of a baby.

A speculum is placed in the vagina, like when you have a normal smear test, and the Mirena is placed into the womb through the cervix. Because it contains the storage of hormone, the stem is slightly wider than in normal IUCD's. This can occasionally lead to difficulties with fitting, especially if you have not had a baby before. In this situation, it would be helpful to use some local anaesthetic. It should be fitted by someone who has been trained and has experience in fitting IUCD's.

It is a good idea to take some painkillers a couple of hours before the fitting - this will help reduce any discomfort. A good choice is Ibuprofen 400 mg, which can be bought over-the-counter at a chemist (please check that this is safe for you). Most women do not find the insertion procedure very uncomfortable - usually much less than expected.

Once the IUS is in place, you won't be able to 'feel' it in your womb. Your doctor will show you how to check for the strings, and it is very unusual for your partner to be aware of it during intercourse. After fitting, a further appointment should be made for six weeks later to check the strings can still be seen. Yearly checks are advised after this appointment.

Removing or Changing the Mirena

Removal involves a speculum examination again and the IUS is removed by pulling on the strings. This is only uncomfortable for a second or two as it comes out. The hormone effect on the lining of the womb is reversed within a month and normal periods and fertility returns.

The IUS will last 5 years and, if required, a new one can be inserted at the same time the old one is removed.

Mirena for Heavy Periods

Although the IUS was originally developed as a contraceptive, the discovery that it leads to much lighter periods was a great bonus. Many gynaecologists now suggest the Mirena as a treatment for heavy periods if tablet treatment doesn't work.

After 3 months use, the average blood loss is 85% less, and by 12 months the flow is reduced by 97% every cycle. About one third of women using the IUS will not have any periods at all. Although women initially find it a bit unusual not having periods, it doesn't cause any problems. There is no 'build up' of blood, because the hormone in the IUS prevents the lining of the womb from building up at all. Often it is the excessive thickening of this lining that is the cause of the problems in the first place.

One study looked at 54 women who had heavy periods and were awaiting hysterectomy. They all used the Mirena, and just under 70% were taken off the waiting list because they were happy with the treatment. In another study of 50 similar women, 82% avoided major surgery [4].

The Mirena is now licensed for treating heavy periods, and although this official licensing is relatively new, it has been used 'off-license' for some time in this way.

Painful Periods

Although the IUS isn't primarily used for painful periods, two studies have found that it does help in many cases (as often as 80% of the time). If painful periods persist, it is usual to rule out any other problems with a laparoscopy.

Fibroids

Large fibroids are a common cause of heavy periods. If they are so large, or in such a position that they make the inside of the womb an abnormal shape, it is unlikely that the Mirena will remain in place, and would not be helpful as a treatment. With small to moderate size fibroids, it is quite reasonable to use the IUS and one study has found that fibroids are less common in women who use the Mirena. A further paper has found that in the 5 women studied, a Mirena actually reduced the size of their fibroids. This is only one report, of course, and the IUS cannot be recommended as a treatment for fibroids based on this alone, though it is very interesting.

Premenstrual Syndrome (PMS)

PMS is a syndrome that is thought to be caused by the varying hormones of the menstrual cycle. There have been suggestions that the IUS may be useful as it will allow a continuous dose of hormones to be given (oestrogen) without the worry of excessive stimulation of the lining of the womb. Usually oestrogens are combined with a course of a progestagen to prevent this, but many women experience PMS-like symptoms with progestagens. At present there is little published in the medical literature about the use of the Mirena in this way, but for severe cases, where hysterectomy is being considered as the only remaining alternative, it would certainly be reasonable to consider this.

Hormone Replacement Therapy (HRT)

There is a growing experience with the use of the IUS for women who require hormone replacement therapy, but who have either bad PMS-like symptoms or erratic bleeding on normal HRT preparations. The IUS with continuous implants, tablets or patches of oestrogen provides good symptom relief with minimal side effects. As its use in this way is not generally established in the UK, this would normally be prescribed under the care of a gynaecologist. In other countries (eg. Finland) the IUS is licensed for use in this way and can be routinely used for up to 5 years.

Ectopic Pregnancy

Women who have experienced an ectopic pregnancy are at a greater risk of this happening again in future pregnancies. For this reason, they are advised to choose a type of contraception that does not increase this risk any further - in particular they are encouraged to avoid IUCD's, as these are known to increase this risk. The risk of ectopic pregnancy is very much lower with the IUS than in women not using any contraception (60 times lower, in fact). Although perhaps not a first choice, the IUS may be considered when other contraceptives are really not suitable. As with most decisions in medicine, it is about the balance of risk.

Side Effects

Expulsion: In the early months of use, there is a very small chance that the IUS may dislodge and come out, either in part or altogether. This risk may be greater than with other IUCD's, presumably because it is that bit larger. There may be symptoms such as bleeding or persistent pain not relieved by simple pain killers, or it might be passed without any discomfort at all. As the system reduces blood flow, sudden return of heavy periods might suggest this has happened.

Hormonal Problems: Although the IUS delivers its hormone directly to the lining of the womb, it does lead to a slight increase in progesterone levels in the blood stream. The levels are much lower than that found with the progestagen-only pill (POP) and usually don't lead to side effects. If they do occur, most often they are mild and only last up to 4-6 weeks. Side effects have included headache, water retention, breast tenderness or acne.

Ovarian Cysts: Progestagen hormones increase the chance of benign, simple ovarian cysts. This is more common with the higher hormone levels associated with the progestagen-only pill. Overall the risk is about 3 times higher (1.2% in IUS users versus 0.4% normally). These cysts most often do not require any treatment and resolve on their own over 2-3 months. It is usual to arrange follow-up ultrasound scans over this time if they do occur. The most common symptoms of a cyst is abdominal pain that doesn't settle with simple painkillers.

Bleeding Problems: These are without a doubt the most common problem associated with the Mirena. It takes about 3 months for the lining of the womb to thin down and during this time bleeding can be erratic or even heavy at times, but almost always settles after 3-6 months. During the first month, 20% of users experience prolonged bleeding of more than 8 days duration, but by the third month only 3% have prolonged bleeding.

Pelvic Infection: In general IUCD's increase the risk of infection of the womb, tubes and other pelvic organs. Studies looking at Mirena suggest that this may not be the case, with the IUS being protective against infection, particularly in the age group most at risk (<25y). Although this would fit with the thickening of the cervical mucus preventing infection getting through the cervix, this finding is not universal in all studies. The actual long-term risk of infection is very low, at less than 1% with 5 years' use. A World Health Organisation study of over 22,000 users found that the infection risk was only increased in the first 20 days after insertion. This demonstrates the need to rule out infection in high-risk women before inserting the IUS, and in this group a Chlamydia screen is advised.

Cost: The IUS costs the NHS around 90, so as a contraceptive the initial outlay is quite a lot. There is no cost to women who choose this - as with all contraceptives, they are free. If it is used as a treatment for heavy periods and contraception is not also required (eg. if you've had a sterilisation already), then the cost is the standard prescription price.

Conclusion: The IUS is an effective contraceptive and treatment for heavy periods. It reduces menstrual pain, may be used with small to moderate fibroids and has the potential as a treatment for severe PMS. It is associated with a low risk of ectopic pregnancy and infection. It may be more difficult to insert than standard IUCD's, in some women can lead to mild hormonal effects, and commonly causes irregular bleeding in the initial months, though this usually settles by 3-6 months. It is a particularly good treatment choice for women with heavy periods who wish to avoid major surgery.

Birth Control Pill

To put off parenthood or just to avoid unwanted pregnancies, many couples have made birth control pills a part of their daily routine. In fact, this contraception if one the most popular forms of female birth control. These contraceptive pills can be taken orally and are very effective at preventing pregnancy.

There are mainly two kinds of pills that you will find on the market. One type of birth control pill has artificial estrogen and progesterone while the other is comprised of just progesterone. These usually come in a pack of 21 or 28 pills and have to be taken daily at a particular time of the day. Some newer brands of pills, though, require you to take the hormonal pills for 90 or more consecutive days. To get the contraceptive pill, you will need a prescription from your doctor.

How do the Pills Work?

When you take an oral combination pill (those with both estrogen and progesterone), the hormones present block the release of an egg from the ovary. This is the primary method through which the pill works. The pill also helps in thickening the cervical mucus so that it becomes harder for sperm to move and fertilise an egg in the fallopian tube.

Progesterone-only pills generally do not prevent ovulation but instead thickens the cervical mucus to prevent fertilisation from occurring. Both these kinds of pills may also thin the uterine lining, which can prevent implantation from taking place if an egg is fertilised.

Birth control pills offer no protection against sexually transmitted diseases.

Who Can Use Them?

There are mainly two kinds of pills that you will find on the market. One type of birth control pill has artificial estrogen and progesterone while the other is comprised of just progesterone. These usually come in a pack of 21 or 28 pills and have to be taken daily at a particular time of the day. Some newer brands of pills, though, require you to take the hormonal pills for 90 or more consecutive days. To get the contraceptive pill, you will need a prescription from your doctor.

How do the Pills Work?

When you take an oral combination pill (those with both estrogen and progesterone), the hormones present block the release of an egg from the ovary. This is the primary method through which the pill works. The pill also helps in thickening the cervical mucus so that it becomes harder for sperm to move and fertilise an egg in the fallopian tube.

Progesterone-only pills generally do not prevent ovulation but instead thickens the cervical mucus to prevent fertilisation from occurring. Both these kinds of pills may also thin the uterine lining, which can prevent implantation from taking place if an egg is fertilised.

Birth control pills offer no protection against sexually transmitted diseases.

Who Can Use Them?

Most healthy women can use oral contraceptive pills to avoid pregnancy. However, there are instances where this method may not be suitable and other birth control options may be better. Some typical cases where you should not use birth control pills include:

  • If you are over 35 years of age

  • If you smoke

  • You have a history of heart problems

  • You have known or suspected cancer of the uterus or breast

  • You get vaginal bleeding

  • Have a history of blood clots

  • You have liver disease or inflammation of the liver

  • You get frequent migraines or headaches

  • You have been diagnosed with high blood sugar or high blood pressure

  • You require bed rest after a major surgery

Woman who are under 35 and suffer from epilepsy, diabetes, sickle cell disease or any heart or liver problem should abstain from using birth control pills. Also, some women may have religious or moral objections to using this form of contraception and may prefer to us natural birth control or hormone-free contraceptives

Effectiveness of Pills

Research and use by many women has shown that birth control pills are as much as 99.9% effective in preventing pregnancy when used perfectly. Perfect use refers to taking the pill at the exact same time every day (so that your hormone levels stay consistent) and not forgetting any pills. However, with typical use, the pill may be as low as 92% effective. Typical use means that you do not take the pill at the exact same time each day and that you might sometimes forget to take a pill.

It has been seen that certain drugs like antibiotics, anti-fungals, anti-HIV protease inhibitors, and anti-seizure medications affect the efficacy of birth control pills. Therefore it is always better to ask your physician about the drugs you can take along with the pill. If you are being prescribed a drug, make sure to mention to the doctor that you are taking the birth control pill.

Sometimes vomiting and diarrhoea may also lessen the effectiveness of the contraceptives. Pills can also fail to prevent pregnancy if you miss one or more doses or take an irregular dosage. If you have been sick, are using a medication that can interfere with the pill or miss a dose, consider others methods of birth control, like a condom, until you get your period to help prevent pregnancy.

How to Use the Pills

If you are prescribed 28-day birth control pills, your pill pack will consist of 21 days worth of hormonal pills and seven days of sugar pills. During the seven days of the sugar pills, you will get your period. Women using 21-day birth control pill packs will take only hormonal pills for 21 consecutive days before stopping their pill for one week. During this pill-free week, you will get your period. At the end of the pill-free or sugar-pill week, you will start another pack of hormonal pills. Women on other forms of birth control pills may take the hormonal pills for a longer period of time before breaking for a period.

It is important to take a pill at the same time everyday particularly if you are using the progesterone-only pill. If you delay the time by 3 hours or more, you might have to use another effective birth control method in addition to your pill. Linking your pill taking to a daily activity, like eating breakfast or brushing your teeth, will help you make it a part of your daily routine. Other women find it helpful to set a watch alarm so that they never forget to take their pill.

If you do forget to take a pill, take the missed pill as soon as you remember and continue with your regular schedule. If you miss two or more pills, consult the instructions that come with your birth control pills.

Although the pill is usually effective as soon as you start taking it, it is generally recommended to use a secondary contraceptive method for the first week to month of use.

Advantages

The many advantages of using a birth control pill are:

  • It is safe and easy to use

  • Periods become more regular and lighter

  • Future fertility is not affected

  • Intercourse is not interrupted

  • May protect women from cancer of the ovaries and the uterus

  • Reduces acne

  • Fewer menstrual cramps

  • Protection against pelvic inflammatory disease

  • May reduce your risk of an ectopic pregnancy

Disadvantages

Drawbacks to this contraception include:

  • Has to be taken everyday

  • Does not protect against sexually transmitted diseases

  • Is less effective when take along with some drugs

  • Increase risk of strokes

  • Cannot be taken without a prescription

Side Effects

Many women complain of birth control pill side effects although these discomforts have been reduced to a large extent nowadays as pills contain a much smaller dose of hormones compared to when they were first put on the market. Some of the more common birth control side effects include:

  • Missed period (consult your physician if this happens)

  • Spotting or bleeding, usually during the first three months. If your bleeding is severe, consult with your doctor.

  • Breast tenderness

  • Weight gain

  • Water retention

  • Nausea

  • Mood swings

  • Darkening of the skin

  • Decreased sex drive

These birth control pills side effects usually subside after 2-3 cycles. If symptoms persist, it is always good to keep your physician informed. Though serious problems are not frequent, there are some complications associated with using the birth control pill:

  • Blood clots in the brain, heart, lungs or legs

  • Jaundice (rare)

  • Liver tumors (rare)

  • Gallstones (rare)

  • High blood pressure

Also check out are articles on the risks of birth control pills, on how smoking affects the pill, on the links between the pill and IBD and on how birth control pills affect your libido.

Availability and Cost

The cost of birth control pills will vary according to the brand you use and where you obtain your pills. Some health clinics may provide the pills at a reduced cost or possibly for free. Some insurance policies may cover some or all of the cost of the prescription.

It is very important that you keep your physician informed of any bodily changes while you are taking the pill and to get a complete gynaecological check up done once every year.