The choice of Contraceptive is based on many factors in an individual including effectiveness, side effects, other health concerns that may influence the risk of particular complications and control of other problems such as acne or heavy periods. It is important to discuss all concerns frankly with your doctor and to understand the way a method works and potential issues. Everyone is different.
Barrier methods (condoms and diaphragms) offer ease of use and are readily available however they have a significant failure rate if not correctly used. Condoms offer the additional advantage of protection against sexually transmitted diseases and may be used in that role even if other contraception is used for reliability.
Sterilisation may be suitable for those who have completed their family. Male sterilisation (vasectomy) can be done under local anaesthetic and is a simple procedure performed out of hospital. Follow-up semen analysis after 3 months is recommended to ensure it has been successful. Female sterilisation (Tubal Ligation or Essure ) requires day surgery in hospital. This involves placing a clip over the fallopian tubes at laparoscopy or blocking the tube with a small coil from the uterine side. These should all be considered permanent and careful counseling is recommended before they are performed. Reversal may be possible and IVF is an option if there is a change of heart.
Hormonal methods include the Combined Oral Contraceptive pill (COCP) and progesterone only methods. The latter includes pills, implants, injections and intrauterine devices.
There are many types of COCP however all essentially contain an estrogen and a progestagen. The variations in relative doses and the actual hormones used may offer different advantages to particular patients. The common side effects of estrogen are headache, nausea and an increased risk of blood clots. Facial skin discoloration (Chloasma) may occur in some patients similar to that seen in pregnancy. Estrogen containing compounds should not be used by women at higher risk of clotting (inherited disorders, previous history of clots or severe migraine, smokers over 40), or by those who have had a hormone sensitive cancer (breast) or have liver disease. The common side effects of progestagen are mood change, fluid retention, bloating and weight gain. These are less with some of the newer types of progestagen.
COCP are highly effective if used correctly. Some medications (anti-epileptics for instance) can alter their metabolism and therefore blood levels. A higher dose pill may be needed. Similarly antibiotics or severe diarrhea can decrease absorption and alternate measures may be needed. If concerned always check with your doctor or pharmacist.
While breast feeding women are often keen to avoid medication. If the baby is fully breast fed and there are no periods this offers 98% protection in the first 6 months. However the first ovulation can occur prior to the first period. Women should consider backup if worried and particularly if they are feeding less often or expressing regularly. Condoms, intrauterine devices or the Minipill are suitable. The Minipill contains no estrogen and will not affect milk supply. It works by thickening the cervical mucous and must be taken every day to be effective.
Depot Medroxyprogesterone Acetate (Depo-Provera) is an injectable long acting Reversible progestagen only method which is given every 3 months. It is very reliable as it removes the need for daily pill use. It contains no estrogen making it suitable for women who cannot take this hormone. In common with other progestagen only methods it gives irregular periods and sometimes constant bleeding. With continued use periods will often disappear. The high dose increases the risk of side effects particularly weight gain and mood disturbance. However some women will find this method very effective long term. Once injected it cannot be reversed and needs to wear off. With repeated injections complete reversal may take some time.
Implanon is another long acting reversible method presented as a small flexible rod which is inserted under the skin in the upper arm. Removal leads to restoration of normal hormonal function within days. It maintains hormones in a normal range but blocks ovulation. Irregular bleeding is usual with a small number having no periods. Troublesome, frequent or prolonged bleeding is seen in up to 10% of women.
Intrauterine devices are available in two types and both provide reliable long term contraception for up to 5 years. The Mirena contains a low dose of progestagen. It was designed to treat heavy menstrual loss. It lightens periods in most users and they may disappear in up to 20%. A small number of women experience troublesome frequent and/or prolonged bleeding. Systemic side effects are uncommon although a small number of women experience mood change/dysphoria and fluid retention. The copper device contains no hormones. Periods will continue on as previously though slightly heavier in most cases. These devices are best suited to women in a stable relationship who have had children although the latter is a relative contraindication. Insertion can be more difficult in nulliparous women.