Choices After Abstinence Cover 9:Layout 1 11/15/10 1:54 PM Page 2

How to Pick a Boyfriend or Girlfriend This imaginative tool outlines three types of partners in terms of their desirability, their potential as a date and their risk to each other. It suggests how a girl or boy could decide if someone is a bad or good possibility as a date or mate. This tool has been tried and loved by college and high school students. If you are in the dating game, consider these issues regarding a potential partner. i t ! Don’t talk to them. Walk away if they… o u t b

a • use drugs like heroin, crystal meth or crack cocaine • use violent words or are physically violent against you or anyone else

t h i n k • are disrespectful of others in their life – like their parents, siblings or teachers

o n ’ t • have children they aren’t supporting

D • are currently having sex with another person • tell you they would never use a

! Beware if they… • are much older e t r b • have lots of former partners they have had sex with e v • have ever cheated on a partner in the past

e r • don’t like your friends or your parents • don’t think school is that important d e s • have ever gotten into trouble with the police

o u • don’t listen to you Y • make you feel pressured to do sexual things you don’t want to do This is a LARC-friendly publication. It features the This could work if they… k ! Long-Acting Reversible

o r • listen to you w • respect you Contraceptives, or the • make you feel good about yourself “You Can’t Forget Me” • encourage you o u l d c • have a life plan that fits your life plan methods, including: • The Mirena® IUD h i s ® T Your questions answered at www.managingcontraception.com • The Implanon 2010/11 • The T IUD December 19, 2011 Adolescent prevention initiatives support teens as they explore and determine Choices TABLE OF CONTENTS responsible sexual and reproductive options COMPARING TYPICAL EFFECTIVENESS PAGEOF for their future. ABSTINENCE ...... CONTRACEPTIVE METHODS 1 OuTErCOurSE ...... 3 This book is designed to give YOU the power More effective How to make your WITHDLess than 1 pregnancyrAWAL per ...... method most effective4 to make good choices! We respect your right 100 women in one year to be responsible. : Male ...... After procedure, little or nothing5 to do or remember. CONDOMS: Female ...... 8 Implanon & Nexplanon ParaGard Mirena : Use another method for first 3 Implants IUDs DuAL METHODS/ AWArENESS METHODS ...... months and until there are 9no motile sperm Sex has consequences. on 2 semen analyses. LONG ACTING rEVErSIBLE CONTrACEPTIVES (LArC) ...... Injections: Get repeat injections10 on time Teens who are sexually active and choose not BrEASTFEEDING ...... Pills: Take a pill each day 11 to use any method of have a 90% 6 to 12 per 100 women in one year Patch, Ring: Keep in place, change on time chance of having to deal with a pregnancy (Film, Foam, Gel, Diaphragm and Sponge) ...... 12-14 within the first year of becoming sexually Condom, Diaphragm: Use correctly every THE “GET IT AND FOrGET IT” METHODS ...... single time you have sex15-16 active. Fertility-awareness based methods: Ab- IuDs (Copper IUD (Paragard®), IUD (Mirena®))Withdrawal ...... 17-18 (No deposit, stain or use condoms on fertile days. Newest Teen pregnancy costs taxpayers millions of No return) methods (Standard Days Method and Two Day Almost 50% of teens have never IMPLANON® IMPLANTS ...... Method) mat be easier to 19use and consequent- dollars each year. ly more effective. considered how a pregnancy would The costs to the children born to teen parents (Copper IUD and Oral Contraceptives)Withdrawal,...... :20-22 Use correctly every affect their lives or the lives of those time you have sex. is immeasurable. DEPO-PLess effectiverOVErA® INJECTIONS ...... 23-24 around them. THINK about it! 18 or more pregnancies per Adapted from WHO 2007 and Contraceptive Technology, 100 women in one year 20th Edition. PILLS (Combined Oral ContraceptiveFertility-awareness Pills and Progestin-OnlySpermicides Pills) ...... 25-26 The fact is, babies born to teens often do not Girls who have babies as teens often based methods receive the support they need to grow and raise those children in poverty, alone PATCHES...... 27 develop as well as babies born to adult parents. and dependent on the welfare system. rINGS ...... The Incredible St. Louis Story 28 80% of the fathers of babies born to ...... 29 teens choose to live apart from their Choices AT YOur FINGErTIPS ...... 30-31 children and pay less than $800 a year in child support. We8 wish10,000 you women luck in are making being decisions given contraceptives about abstinence at no and cost birth through control Washington and hope Universityyou find this in St.guide Louis useful to you, Teen pregnancy is preventable! You your partner and your relationship. Your sexual health is an important part of your future! don’t have to change YOUR life plan– 8 47.1% are choosing to use a Mirena* IUD (the levonorgestrel IUD) and 10.5% are choosing a if you have a PLAN for life. Robert ParaGard A. Hatcher, IUD MD, (the MPHcopper T IUD) - SharonSimply A.amazing! Rachel, MA, MPH Aimee M. Moynihan, MSEd, CHES Professor of Gynecology and Obstetrics Center of Excellence for Sexual Health Gynecology and Obstetrics There is a provider Emory8 11% University are having School an Implanon of Medicine implantSatcher inserted. Health Leadership Institute Division of Family Planning in most U.S. counties where you Morehouse School of Medicine Emory University School of Medicine 8 can receive counseling, guidance IUDs and implants are the “you can’t forget me” methods. Almost 70% of women are choosing one of these Special three thanks methods. to Peter W. Hatcher MD, in Portland, Oregon, John Stanley in Atlanta, Georgia, and Anna Handley, and birth control, FREE and Anna Rappaport, and Amy Winter at the Rollins School for Public Health at Emory, for many suggestions that have confidentially! been* Terri incorporated Wynn-Hipps into is thea nurse pages midwife of Choices in Ft.. Bragg, NC. She has inserted about 200 IUDs in the past year. 85% of her insertions are Mirena IUDs. Because of the irregular bleeding at the beginning she tells women: “You may Bridging the Gap Communications, Inc. dislike it for a month, but then you’reCOPYRIGHT going to love it for INFORMATION 5 years.” Choices ©2011 by Robert A. Hatcher, Sharon A. Rachel and Aimee M. Moynihan and Bridging The Gap Foundation. The extent to which this book is used to help others is P.O. Box 79299, Atlanta, GA 30357 now in your hands. Although all rights are reserved, we encourage reproduction of this entire book or parts thereof without seeking permission, so long as you credit Choices and the Bridging the Gap Foundation. We authorize is you published to use the enclosed information, by Bridging if you include theThe citation below.Gap If youCommunications use material from this book, please indicate to readers Phone: 404-875-5001 • Fax: 404-875-5030 of your publication that others may also reproduce or use that portion of your publication at no cost. www.managingcontraception.com P.O. Box 79299, Atlanta, GA 30357 • Phone 404-875-5001 • Fax 404-875-5030 Suggested formal citation: Hatcher, RA, Rachel, SA and Moynihan, AM. Choices. Tiger, Georgia: Bridging the Gap Foundation, 2011. www.managingcontraception.com ISBN# 978-0-9794395-3-7 • Order at www.managingcontraception.com or call 404-875-5001. www.managingcontraception.com WHERE CAN I LEARN MORE? Chapter What you do sexually is an important decision. Start by thinking it through carefully yourself. You may want to ABSTINENCE discuss your decision with another person whom you respect. You may want to pray, meditate, or talk it over 1 with your partner. Some churches and sex education programs have organized support groups or teaching for (Not Having Sexual Intercourse) young people wanting to wait until marriage before having sex. As with any contraceptive choice, you should decide to use it before you become sexually active. Abstinence is no different. Once you have thought it over and talked to another trusted person, clearly communicate your commitment to abstinence to your partner. If she or he does not agree with your decision, consider finding another partner who will also commit to abstinence as a choice.

Four Time Frames in Which to Think About Abstinence: WHAT IS ABSTINENCE? – Abstinence until marriage or until a long term relationship or until you are sure that you are ready bstinence means different things to different people. To avoid sexual activity that can lead to pregnancy, for sex. Waiting until marriage can prevent many complications from sexual intimacy and may be the approach abstinenceA refers to not having “penis-in-vagina” intercourse. For protecting against infection, abstinence means an individual feels most comfortable with in terms of his or her spiritual or moral journey. avoiding vaginal, anal and oral-genital intercourse or participating in any other activity in which body fluids – semen (“cum”), vaginal fluids, blood, breast milk – are exchanged with another person. Here, abstinence refers Secondary Virginity – After having been sexually active, a woman or man can return to abstinence until primarily to not having vaginal intercourse – where the penis enters the vagina. Some people will use other marriage or until a long term relationship or until you are sure that you are ready for sex. A person can always kinds of touching to satisfy their needs (see the section on OUTERCOURSE - p. 3). Others will avoid any kind of choose to return to this long-term approach to abstinence. You always have this option even if you have had touching because it is too tempting. Decisions about sexual intimacy are yours, each and every time. sexual partners already.

Abstinence for a while – This could be until you are certain you are on an effective contraceptive, until both of WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? you have been tested for and are not infected with HIV or any other sexually transmitted disease, or until your partner (or you) returns home from a long trip. 8Abstinence is free and available to all. 8It may be very difficult to communicate clearly with a 8It is extremely effective at preventing both partner about abstinence. Abstinence TONIGHT... TODAY... or NOW! – Each night about 10 million women who do not want to infection and pregnancy. 8Some people find not having sex too frustrating, and become pregnant have intercourse. About 10% (one million) of those acts of intercourse are completely 8It can be started or returned to at any time may feel as though they are “missing out” if they unprotected (no contraceptive). Abstinence today is what these one million women (and men) would be wise in one’s life. choose abstinence. to use – TONIGHT!!! Other options: use a condom, withdrawal or “outercourse.” (See next page.) 8Abstinence may encourage people to build 8If you’re planning to use abstinence and change your relationships in other ways. mind in the heat of the moment, you might not have 8Abstinence may increase the creativity in birth control handy or may have little knowledge a relationship as partners find new ways to about other methods. On any given night, more people use abstinence express intimacy and find pleasure with 8Some people would like to be prepared and have a than any other method of birth control! each other. condom or spermicide available in case they change 8Abstinence may boost your self-esteem as their mind. Others feel that having a contraceptive you are choosing what you consider to be ready and available might tempt them. right for yourself. 8If only abstaining from penis-in-vagina intercourse, 8Abstinence along with increased use of there may be no protection against infections Depo-Provera® and Norplant® (no longer transmitted through other activities such as oral and available) contributed to a fall in teen pregnancy rates in the 1990s. anal intercourse and genital touching (“mutual ”). 8Abstinence has no medical side effects. 8Abstinence-only sex education programs have been shown NOT to be effective.

1 2 www.managingcontraception.com www.managingcontraception.com Chapter Chapter WITHDRAWAL=PULLING OUT 2 OUTERCOURSE 3 “No deposit, no return” WHAT IS “OUTERCOURSE”? WHAT IS WITHDRAWAL? utercourse, as opposed to intercourse, refers, in a playful manner, to types of ithdrawal means pulling out the penis from the vagina during sex. When the man senses that he is about to Osexual intimacy which do not involve the penis entering the vagina or anus. Some come,W he pulls his penis out of the vagina. The man ejaculates (comes) outside of the vagina. Sperm is not deposited in examples include: the vagina, so pregnancy will not occur. Withdrawal requires commitment to the method in advance and takes a lot holding hands hugs kisses of discipline! If the woman has not had an orgasm, the man can stimulate her in other ways after withdrawal. Among petting above the belt oral-genital contact petting below the belt average couples who use withdrawal, about 27% will experience an accidental pregnancy in the first year. If withdraw- mutual masturbation touching massaging al is used consistently and correctly, only about 4% will become pregnant in an entire year of having sex.

WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES?

8Withdrawal works best when used with another 8Couples often want to keep thrusting. They don’t 8Outercourse is always an option...there are no 8Outercourse requires a lot of willpower for both method, even methods (see p. 9). want to stop when it is time to pull out. supplies needed and it is free! partners. It requires communication to make 8Withdrawal is always an option. It is completely 8The man may worry: “Will I withdraw in time?” And sure both partners are committed to not having 8For couples who commit to outercourse, there is private and is definitely better than nothing. the woman may worry: “Will he withdraw in time?” sexual intercourse. no worry about pregnancy. For many women, it may This concern may decrease their enjoyment of be more pleasurable (and even more likely to lead to 8If vaginal sex does occur, the couple may not 8No fluid, or much less fluid, is deposited into the intercourse. orgasm) than traditional intercourse. have any method of birth control or STD woman’s vagina (may be less messy). 8 protection to fall back on. 8Withdrawal causes no medical complications. Withdrawal provides poor or no protection against 8No fluid is deposited in the woman’s vagina. There sexually transmitted infections, including HIV. is some protection, but not total protection, against 8One partner or both partners may really want 8No supplies are required. Withdrawal is free (except 8 sexually transmitted infections. to have vaginal intercourse or one or both for the cost of an unintended pregnancy should a Sperm, in small numbers, may be present in the pre-ejaculatory fluid, or “precum”, that comes out of 8There are no medical complications. partners may be thinking: “Is this going to go failure occur). further than I want?” These thoughts and the penis before ejaculation. 8Outercourse can increase emotional closeness 8With practice, withdrawal may increase a man’s concerns may decrease enjoyment. 8Men with premature or unpredictable ejaculation between individuals. understanding and awareness of his sexual response 8Oral sex can spread some sexually transmitted may not be able to use withdrawal. 8Outercourse may be a more cycle. infections. 8A man’s cooperation and commitment to pulling out acceptable practice in some cultures 8Since there are no barriers, chemicals or hormones at the right time is needed for withdrawal to work. and in some religions. used, withdrawal is an option for those whose values go against use of artificial contraception.

Tonight! It’s withdrawal or nothing!! Is it worth the effort? Yes, definitely YES!!!

3 4 www.managingcontraception.com WHAT ARE THE ADVANTAGES? (continued) WHAT ARE THE DISADVANTAGES? (continued) Chapter 8To decrease the chance of the condom slipping 8Some people are sensitive (or allergic) to latex or CONDOMS: MALE down the penis or falling off in the vagina, pull the find the smell unpleasant. They may use polyurethane 4 penis out of the vagina right after ejaculation. DO condoms: Durex-Avanti®, Trojan-Supra® or FC® Female NOT continue thrusting after an orgasm! Condoms. Using BOTH a condom AND another contraceptive 8Practice putting a condom onto a banana! This will 8Buying, discussing and deciding to use, putting on, gives excellent protection against pregnancy and infection! make it easier to use condoms during sex. and getting rid of condoms may be embarrassing. 8With condoms, the risk of infertility from sexually Condoms decrease enjoyment of sex for some couples. transmitted infections is decreased. 8Condoms are fairly easy to get and usually do not WHAT TYPES OF CONDOMS ARE THERE FOR MEN? cost a lot - many clinics give them away for free! 8Lubricated condoms are a good contraceptive option ondoms are made of latex (often called “rubbers”), polyurethane (plastic), or natural membranes (often during breastfeeding – some women are bothered calledC “skins” and made from the intestine of sheep). Polyurethane and natural membrane condoms may be used by a dry vagina during breastfeeding. They are also a by couples when either partner is allergic to latex. Condoms look like long thin balloons before they are blown good option as a backup for other methods. up. Condoms act as a barrier or shield – they prevent pregnancy by stopping sperm from going into the vagina. The condom needs to be put onto the penis before the penis comes into any contact with the vagina. Among average couples who start using latex male condoms as their only method of birth control, about WHERE DO I GET MALE CONDOMS? 15% will have an unintended pregnancy in the first year. If condoms are used consistently and correctly, about 2% of first year users will become pregnant over the course of an entire year. Condoms can be purchased at drugstores, supermarkets and gas stations. Some health departments and family planning clinics give away condoms. They may also be purchased online, just be sure to plan ahead. WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? Tonight! We use a condom or we don’t have sex! Is it worth the effort? YES! Definitely yes! 8If the woman puts the condom on the man, it can be 8While very effective if used correctly and consistently Here’s the math: Among couples who do not use any contraception, 85% will become pregnant within a fun for both partners! (every time!), the condom ends up not being used year. If latex condoms for men are used correctly and consistently, about 2% of couples will become pregnant 8Condoms are safe for women and men. perfectly by most couples. Average couples who over the course of an entire year. This method is very effective if used correctly every time! 8The male condom is very effective at preventing choose condoms as their birth control have about a 1 both pregnancy and infection if used perfectly. in 6 chance of getting pregnant during their fist year of relying on the condom. 8Sexual intercourse may be enjoyed more by some couples, in part because there is less fear of STIs, HIV, 8Unless the woman puts it on as a part of foreplay, the and pregnancy. condom may interrupt sex. 8Condoms reduce the risk of cervical cancer because 8Condoms require some practice to learn how to use. there’s less risk of HPV infection. 8When putting the condom on the penis you must 8Men “last longer” when they use condoms. avoid tearing the condom or putting a hole in it with Prolonging sex may make sex more fun for both the finger nails, a ring or anything sharp. This includes woman and the man. anything sharp in the mouth! 8Condoms come in many colors, sizes and with or with 8YOU CAN’T USE OIL-BASED LUBRICANTS such as out ribbing. Variety is exciting! Vaseline®, sun tan oil, or Crisco® with latex condoms! These products can put a hole in a latex condom in a 8Condoms make sex less messy by catching the matter of seconds. semen. Less discharge. Less odor. 8Some men have trouble keeping their erection with a 8Remember, penises and condoms come in different condom on. sizes! Find a condom that fits! 8The man must pull out soon after ejaculation 8Use a water or silicone-based lubricant to enhance (“coming”). If he becomes soft, the condom can fall off comfort and pleasure and decrease breakage. and be left in the vagina without the couple knowing that this has happened.

5 6 HOW TO USE A MALE LATEX CONDOM www.managingcontraception.com (...Or rubber, sheath, prophylactic, safe, french letter, raincoat, glove, sock) Chapter CONDOMS: FEMALE Talk/Think about condom use with partner. Make the FIRM commitment, in advance, 5 to use condoms with each and every sexual act (vaginal/oral/anal) - no exceptions! (FC® and FC2®)

WHAT IS THE ? Keep a supply of condoms handy - store condoms in a cool, dry place away from sunlight and check the expiration date before use. Have a package of Plan B One-Step available. he female condom (FC®) is made of a thin plastic called polyurethane. This is NOT latex or rubber. FC® comes inT only one size: 15 centimeters (about 6 inches) in length and 7 centimeters (about 3 inches) wide. It is open at one end and closed at the other. Both ends have a flexible ring used to keep the condom in the vagina. The flexible inner Use NEW condom before each and every sexual contact. ring at the closed end is inserted into the vagina as far as possible and helps keep the condom in place; the inner ring may be removed or left in place in the vagina. The larger outer ring remains outside the vagina. The new female condom, FC2® reached pharmacies at the end of 2009. It is softer and makes less noise than the original FC® because it is made from a different material called nitrile. It is less expensive to produce USE CONDOM CORRECTLY and buy. Complete information about this contraceptive is available from your clinician, from the package insert, Before putting on the condom, check to see which way the condom unrolls. Put the condom onto the penis before the penis has ANY contact with the vagina. or www.femalehealth.com. Among average couples who start using FC®, about one in 5 (21%) will have an NOTE: A condom can be put onto a penis that is not fully erect. unintended pregnancy in the first year. If, however, these condoms are used consistently and correctly every (If uncircumcised, pull back foreskin before unrolling condom.) time, about 5% of women using them will become pregnant in the course of an entire year. Unroll condom all the way down to the base of the penis (down to hair). If the woman puts the condom on for the man it may be more fun for both him and her! Smooth out air bubbles. Make sure condom fits (condoms come in various sizes). WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? 8Female condoms give women more contraceptive 8The female condom is large and some feel it is unattractive control and a sense of freedom. The female or odd-looking. Although it looks different and may appear condom is an option for a woman who cannot unusual at first, its size and shape allow it to protect a greater get a man to use a condom. area. Many of the couples who have used it like the way it feels. SAFE! Add water or silicone-based lubricant UNSAFE FOR USE WATER BASED OR SILICONE to outside of condom if desired. WITH LATEX CONDOMS* 8Female condoms give women a new option in 8Some women do not like the idea of putting fingers or a preventing both pregnancy and sexually LUBRICANTS SAFE FOR USE Aldara cream foreign object into their vagina. It can be large and bulky WITH CONDOMS Baby oil or cold creams transmitted infections (especially against HPV and for some women, and can be difficult for some women to Astroglide® Edible oils (olive, peanut, herpes, since it covers more of the outer genitals). place it into the vagina. Condom must be used throughout sex. Water and saliva corn, sunflower) Check periodically that condom is still 8Women don’t need to see a clinician to get it. 8It will not work if the man’s penis enters the vagina outside of Glycerin in place. Head and body lotions No prescription or fitting is needed. All I-D® Lubricants Massage oils the female condom. The penis must be directed into the condom. Aloe-9 Mineral oil 8The female condom can be put in up to 8 hours 8The female condom is not available in as many stores as the ® H-R Lubricating Jelly Petroleum jelly in advance. male condom. It may be hard to find, so call the store in advance or ® Change condom if sex is prolonged or K-Y Jelly Rubbing alcohol plan to purchase them online. Prepair® if penis is exposed to different orifice Shortening 8Your partner can insert it and make it part of (mouth or anus). Probe® Suntan oil and lotions lovemaking. 8Female condoms are much more expensive than male ® AquaLube Whipped cream 8Condom is pre-lubricated inside and outside. condoms. Because of the cost, some couples have washed ForPlay® Vegetable oil and cooking oils and reused female condoms, though female condoms are ® After ejaculation: The female condom can be used if either Gynol II Clindamycin 2% vaginal cream only FDA approved for single use and it is recommended Wet® Hold rim of condom and carefully partner is allergic to latex (rubber). Vaginal yeast infection they be discarded after being used once. Cornhuskers Lotion withdraw penis before loss of erection. medications in cream or 8The female condom is a good option during Silicone Lubricant suppository form breastfeeding. 8The inner ring may cause discomfort; if it does, it should be deLube® • Butoconazole cream removed. Spermicide • Clotrimazole cream or tablet 8The female condom can be used for . * 8The female condom is slightly less effective than latex male Slippery Stuff • Miconazole vaginal suppository 8Breakage is rare. RELAX. Check for breakage; Dispose of condom • Terconazole ointment, cream condoms in preventing pregnancy. in trash (do not flush down the toilet!). If condom or vaginal suppository NOT RECOMMENDED! breaks, slips, falls off or is not used, use EC (see p. 21 for information on Emergency Contraception). If *These lubricants/vaginal products WHERE DO I GET FEMALE CONDOMS? Spermicidal condoms are no can be used with polyurethane condoms * not already available, call 1-888-NOT-2-LATE for EC. Female condoms are sold at some drugstores and at some supermarkets. They may also be available at women’sclinics. Call in longer recommended although Wash areas exposed to body fluids (penis, vulva, etc) spermicides do not damage latex with soap and water or personal wipes. advance to be sure. They may also be purchased online, but be sure to plan ahead. They have been sold in packs of three or six and cost $3.30 to $6.00 per condom. The package comes with a leaflet that explains how to use the condom and small packets of additional lubricant. To learn more about female condoms, call your clinician or call 1-800-274-6601 or visit www.femalehealth.com. 7 8 www.managingcontraception.com www.managingcontraception.com Chapter Chapter 6 DUAL METHOD 7 BREASTFEEDING Nature’s Way of Spacing Babies WHAT IS DUAL METHOD?

ecisions about contraceptives should involve both the need to preventD unplanned pregnancies and the need to prevent STIs. WHAT IS THE CONTRACEPTIVE EFFECT OF BREASTFEEDING MY BABY? “Dual method” (“double” method) works to achieve this! We know that birth control methods that are most effective in prevent- f you just had a baby and are feeding your baby only milk from your breasts (no formula), it is quite likely ing pregnancy – hormonal contraceptives, sterilization, and the thatI your periods will not return for a number of months. If this is the case for you, then you probably won’t get (IUD) – do not provide protection against STIs. pregnant during the first 6 months of breastfeeding. After your baby is 6 months old, the contraceptive effect On the other hand, “barrier” contraceptive methods (specifically of breastfeeding decreases. The pregnancy-prevention effect of breastfeeding also decreases when your periods male condoms) provide effective prevention against STIs when return or you start giving your baby formula or foods other than breast milk. At this point, you definitely need to used consistently and correctly, but are not as effective as the others add additional methods to protect against pregnancy. in preventing pregnancy. The idea of dual methods of contracep- tion is to use BOTH a method that is highly effective at pregnancy prevention AND one that is highly effective at prevention of STIs. WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? Bottom line: use condoms with your other contraceptives. 8Breastfeeding can be about 98% effective as 8Breastfeeding does not keep all women from having WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? contraceptive for up to 6 months. This protection their periods, and is not an effective contraceptive after is greatest if the baby is put to the breast periods return. 8Dual protection for the prevention of pregnancy 8Increased cost with the need to pay for more than frequently (including at night) and breast milk is 8It is difficult to tell when breastfeeding stops working and STIs. one method of birth control. not supplemented by other foods. as birth control. The effectiveness of breastfeeding 8Peace of mind from knowing that you are extra 8Users must be properly educated on more than one 8Breastfeeding helps the mother’s (womb) after 6 months is greatly reduced. protected. method and know how to use them together. return to normal . 8This method does not work as well if the baby is fed other 8The effectiveness of using more than one method to 8 Breastfeeding helps the mother return to her pre- foods in addition to breast milk. If the baby is fed foods prevent pregnancy is not known. It is definitely more pregnant weight. other than breast milk, using a spoon rather than a bottle effective, but exact numbers are difficult to 8Breastfeeding is simply the best way for a mother is best for contraception from breastfeeding. If the mother determine. to feed her baby – “BREAST IS BEST!” It encourages works outside of the home, pumping milk often helps bonding between mother and baby and helps the improve the effectiveness of breastfeeding as a contraceptive. baby have more immunity against infection. FERTILITY AWARENESS METHODS: Four Approaches 8Some women are bothered by a dry vagina while 8Breastfeeding decreases or stops monthly periods, 1. Standard Days Method 3. Method (BBT) breastfeeding. This is normal. Intercourse may be more especially for the first months after the baby is born. For women with most cycles 26 to 32 days long, Assumes early morning temperature measured comfortable if you use a water or silicone-based avoid sex on days 8-19 (white beads on Cycle before arising will increase noticeably (0.4o to 0.8oF) 8Breastfeeding generally does not interfere with lubricant in the vagina. Bead necklace). Beads can be ordered from with ovulation. Abstinence begins first day of sex, and breastfeeding may be pleasurable 8Breastfeeding women must be willing and able to eat www.cyclebeads.com. menstrual bleeding and lasts through 3 consecutive (physically and emotionally) for some women. days of sustained temperature rise (at least 0.4oF) lots of healthy foods. 8Breastfeeding may have a slight protective effect 8If the mother is HIV-positive, there is about a 15%-30% 4. Symptothermal Method against ovarian and pre-menopausal breast cancers. chance that HIV will be passed to her baby through her Combines at least two methods. Usually cervical 8Breastfeeding helps protect the baby against mucus changes and BBT. milk. Breastfeeding is not recommended for HIV-positive 2. Cervical Mucus Ovulation Detection diarrhea and ear infections. This is because the mothers who have other safe and healthy food available Women check quantity and quality of mucus on 5. Two-Day Method mother’s antibodies are passed to her newborn for their babies. There are certain drugs an HIV-positive the vulva with fingers or tissue paper Similar to cervical mucus baby through breast milk. breastfeeding mother can take to reduce (but not • Post menstrual mucus: scant or undetectable method. A woman asks eliminate) the risk of transmitting HIV to her baby. • Pre-ovulation: cloudy, yellow or white, sticky herself “Did I have • Ovulation: clear, wet, stretches, sticky, slippery secretions today & 8Some women have an inadequate milk supply. • Post-ovulation - fertile: thick, cloudy, sticky yesterday?” If no, OK • Post-ovulation - Post-fertile: scant or to have intercourse. undetectable 9 10 www.managingcontraception.com Chapter 8 SPERMICIDES Spermicides with the Diaphragm Film, Foam and Gel WHAT IS A DIAPHRAGM? WHAT ARE SPERMICIDES? diaphragm is a flexible rubber dome-shaped device. Spermicidal gel is applied to the inside of the diaphragm priorA to inserting it into a woman’s vagina. The diaphragm may be inserted up to 6 hours before sex so that it cov- permicides are a chemical called Nonoxynol-9 (N-9) that kill or destroy sperm and also blocks the semen from ers the (the opening to the uterus). The diaphragm acts as a barrier that blocks the man’s semen from enter- enteringS the cervical canal, thus stopping sperm from reaching the egg. The spermicide is placed on or near the ing the cervix AND the spermicidal gel placed onto the diaphragm kills sperm and physically blocks the cervix. cervix, the opening of the uterus. It should be inserted less than 1 hour, but at least 15 minutes before intercourse. Among average couples who start using the diaphragm as their method, about 16% will have an accidental preg- Vaginal contraceptive film (VCF) is a 2 inch by 2 inch clear, paper-thin film that is placed near the cervix and dis- nancy in the first year. If the diaphragm is used consistently and correctly, about 6% will become pregnant. solves in seconds. Contraceptive foam is dispensed from a pressurized canister into an applicator and placed into the woman’s vagina, similar to tampon insertion. Spermicidal gel is either dispensed into an applicator from a tube (similar to a toothpaste tube) or in pre-filled applicators and then placed in the vagina. Complete information about WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? these contraceptives is available from the package insert accompanying VCF film, foam, or gel. The effectiveness of spermicides is NOT GOOD. Among average couples who use vaginal spermicides as their 8The diaphragm can be put in place up to 6 hours 8This method is not very effective – 16 in 100 before sex. typical couples using the diaphragm will method of birth control, about 29% will experience an accidental pregnancy in the first year. Even if vaginal spermicides experience an accidental pregnancy in the first year. are used consistently and correctly, about 18% will become pregnant. Because of their relatively high failure rates, it is recom- 8It can be left in place without reapplying spermicide for up to 24 hours after first being placed. 8The diaphragm must be fitted by a clinician and mended that spermicides be used with another method such as male condoms, withdrawal or emergency contraceptive pills. 8Your partner can put it in as part of lovemaking. re-fitted after the woman has a baby, an , , or gains as little as 15 pounds because 8There are no hormones involved, and thus, there are WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? of changes to the cervix. no hormonal side effects. 8Putting in the diaphragm may interrupt sex. 8Spermicides give women control over contraception. 8Some find spermicides messy and the taste unpleasant. 8The penis can remain inside the vagina after 8They can be bought at most drug stores. 8Women who are not comfortable touching their ejaculation. 8Using the diaphragm may increase a woman’s risk for urinary tract infections, and if left in too No prescription is needed. vaginas may find application of spermicides awkward. 8It may be used during breastfeeding after the vagina long, may increase her risk for toxic shock 8Foam and gel can be put into the vagina 20 minutes 8Spermicides are not as effective as other contraceptives. If and cervix have returned to their non-pregnant shape. syndrome (TSS). before sexual intimacy, but it is also effective 100 couples use it correctly every time for one year immediately if you want to have sex right after the failure (pregnancy) rate is high: 15%. The average 8The diaphragm must be left in place 6 hours putting foam into the vagina. (Film must be placed in or typical user failure rate is even higher: 29%. after the last act of intercourse. the vagina at least 15 minutes before sexual intimacy.) 8Film must be inserted at least 15 minutes before sexual 8If a woman doesn’t like touching her vagina, the 8Your partner does not need to help. intimacy, which may interrupt sex. A woman should wash diaphragm may not be a good method for her. 8The man’s penis can remain inside the vagina after her hands with soap and water before putting film in and 8Some women may find it difficult to insert a ejaculation. dry her hands carefully or the film will stick to her fingers. diaphragm correctly. 8Spermicides are very safe and no hormones are 8Contraceptive film, foam and gel need to be reapplied 8The diaphragm may slip out of place during sex. involved. each time you have intercourse. If a woman changes sexual positions, she may want to check to see that the diaphragm is still 8They may be used alone or with a diaphragm or a 8Some people may be sensitive to N-9 or find it causes covering the cervix. condom and can serve as immediate back-up if a irritation of the vaginal lining. For those people, condom should break or diaphragm slips. the irritation might increase the likelihood of sexually transmitted infections or urinary tract infections. 8They add lubrication and moisture, which may heighten satisfaction in both partners. 8Spermicides do not protect against HIV or other WHERE CAN I GO TO GET A DIAPHRAGM? sexually transmitted infections. Use a condom if you You must be fitted for a diaphragm in a clinician’s office. Be sure you are shown how to insert and re- 8They can be used during breastfeeding. or your partner may be at risk. move the diaphragm. You should also walk around your clinician’s office with the diaphragm in place to make sure it is comfortable for you. WHERE DO I GO TO GET CONTRACEPTIVE FILM, FOAM and GEL? You must go to a pharmacy to get the actual diaphragm and the spermicide to use with it. Complete Film, foam and gel may be purchased at drug stores and supermarkets. information about this contraceptive is available from your clinician or from the package insert that comes with the diaphragm. Diaphragms are not widely available in the today. What about spermicidal condoms?Although spermicides do not damage latex, condoms lubricated with spermicide are no longer widely available, nor are they generally recommended.

11 12 www.managingcontraception.com Spermicides: Sponge Chapter LONG ACTING REVERSIBLE CONTRACEPTIVES WHAT IS A SPONGE? 9

he Today® sponge is no longer being produced as of 2008. Sponges made before There are now 3 Long Acting Reversible Contraceptives (LARCs): the Implanon productionT ceased may still be available for purchase. The Today® sponge is a pillow-shaped polyurethane sponge containing N-9 implant, the Mirena IUD and the ParaGard IUD. spermicide that is placed in the vagina over the cervix. The spermicide in the sponge kills sperm and the sponge acts as a barrier to absorb sperm and block sperm from entering the cervix and uterus. There is just one size. The concave dimple on one side of the sponge fits over the cervix. On the other side is a loop (strap) to make it easier IMPLANON IMPLANTS to remove the sponge. The sponge is moistened with tap water prior to use and inserted deep into the vagina. With the sponge, it really matters if the woman has ever had a baby. Among average couples who initiate mplanon implants are inserted under the skin, where they remain ef- use of the sponge, about 14% of women who have not had a baby will experience an accidental pregnancy in the fectiveI for 3 to 4 years, maybe longer. Irregular spotting and bleeding may first year; 27% of women who have had a baby will experience an accidental pregnancy in the first year. If the improve over time. The total days of bleeding a woman experiences are sponge is used consistently and correctly, about 9% of women who have not had a baby and 21% of women who diminished by Implanon. In clinical trials, no women ovulated in the first 30 have had a baby will still become pregnant in the first year. Because of its higher failure rate when used alone, it months of using an Implanon implant. is recommended that the sponge is used with another method such as male condoms or withdrawal.

WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES?

8The sponge is a good non-hormonal barrier 8The sponge is not very effective (see above), MIRENA IUD alternative to condoms. especially for women who have had a baby because of changes of the cervix. 8Because the sponge can be inserted several hours irena is placed into a woman’s uterus, where it remains effective for 5 before sexual intimacy it can make sex more spontaneous. 8It does not protect against STIs or HIV. tom 7 years, maybe longer. Mirena has so many non-contraceptive benefits. It 8It can be left in place up to 30 hours after initial 8It can increase a woman’s risk for urinary tract is used to prevent or treat menstrual pain, menstrual blood loss, endome- insertion with no need to re-apply additional spermicide. infections. trial cancer, uterine fibroids, endometriosis and dysfunctional uterine bleed- 8It is safe to use and there are no hormonal side effects. 8It must be in place at least 6 hours after ejaculation. ing (DUB). After the first year, 50 to 75% of women using Mirena IUDs are 8The man’s penis can remain in the woman’s vagina 8It should never be used by a woman who is ovulating. after ejaculation. menstruating because it may increase her risk for 8It can be used by women who are breastfeeding once toxic shock syndrome (TSS). the cervix has returned to it’s non-pregnant shape. 8Insertion and removal may be difficult for a woman 8Sponges are sold over-the-counter and do not require who is uncomfortable touching her vagina. PARAGARD IUD a pelvic exam for fitting. One sponge fits all women. 8The sponge may absorb a woman’s natural vaginal lubrication, causing dryness. Use of additional lubricant is recommended. araGard is placed into a woman’s uterus, where it remains effective for 10P to 12 years, maybe longer. While causing increased bleeding and/or pain in the first several months, in the long run, ParaGard has minimal effects on the physiology of a woman’s periods, including the likelihood of ovula- WHERE CAN I GO TO GET SPONGES? tion. ParaGard IUDs are, by far, the most effective emergency contraception The Today® sponge is sold at drugstores in boxes of 3 or 6 and cost about $3 per sponge. They may also be pur- and may be inserted within 5 to 8 days of unprotected sex. Only 1 in 1,000 chased online at www.todaysponge.com. women who receives a ParaGard IUD for emergency contraception be- comes pregnant. WHERE CAN I GO TO GET Choices? Visit the website www.managingcontraception.com • Great Prices for Large Quantities Bridging the Gap Communications, Inc. P.O. Box 79299, Atlanta, GA 30357 Phone: 404-875-5001 • Fax: 404-875-5030

13 14 Chapter 10 THE “GET IT AND FORGET IT” OR LARC* METHODS & WOMEN’S PERIODS SOME PHYSIOLOGY: MENSTRUAL PAIN: Number of eggs a woman has: 1 Menstrual cramps and pain are serious. At 6 to 8 weeks of embrionic development...... 6 to 7 million Implanon implants, as well as How common in Swedish 19 year-olds? 6 At birth...... 1 to 2 million combined pills, patches, rings Breastfeeding 72% report painful periods At time woman has first period...... 300,000 and injections stop ovulation may stop ovulation 15% had to limit daily activitites At age 37 or 38...... 25,000 from the ovaries. from a woman’s 8% missed school or work every cycle At menopause (average 51.3)...... 1,000 or so ovaries 38.2% regularly used medical treatment Average menstrual blood loss...... 30-40 cc (1.01 - 1.36 oz.) UTERINE MUSCLE OVARY A woman’s capacity to become pregnant is falling slightly as she ages. Dr. Kate Miller (Univ of Pennsylvania) encourages women An important message: The biological clock is ticking. to recognize that “this monthly discomfort (cramps, pain, FALLOPIAN TUBE fatigue, irritability) is simply not obligitory.” 7 All these con- A. Menstrual Bleeding or menses occur in women UTERINE CAVITY traceptives definitely may help: the Mirena IUD, birth control starting on average at age 12.8. Heavy or painful pe- riods can be treated. This awareness can remarkably pills, rings, patches, injections and Implanon implants. improve the quality of a woman’s life. During the first month of Mirena use, a woman has more bleeding Hormones in a womAn’s cycle 2 WHERE CONTRACEPTIVES WORK Pelvic Infections: days than non-bleeding days. After six months, the Tubal sterilization blocks passage Infections of the fallopian tubes are serious average woman bleeds one day per month and loses of sperm up the fallopian tube, sometimes causing chronic pain and infertility. 90% less blood. Menstrual blood loss decreases 7 cm Number of episodes Likelihood of slightly in women using Implanon implants and and passage of the egg down the of pelvic inflammatory both tubes being increases somewhat in women using copper IUDs. Estradiol Progesterone (D) Average fallopian tube Progesterone disease (PID): completely blocked: 8 500 pg 10 ng/mL peak in ParaGard, the Copper T Intrauterine Device B. Each cycle, FSH causes about 10-15 eggs start to ovulatory cycle 1 11.4% or about 10% mature. Many are called, but only one is chosen. Only (IUD), works primarily here, preventing ascent 2 23.1% or about 25% one will respond to luteinizing hormone (LH) and (B) LH (D) Progesterone of sperm into fallopian tubes 3 54.3% or about 50% 8 ovulate. Mirena IUDs, ParaGard IUDs and Implanon implants do not The levonorgestrel Intrauterine Device (IUD) called cause pelvic infections. But they also do not prevent sexually C. Estradiol is the main female sex hormone. Mirena® decreases by about 90% the amount of transmitted infections. All women using Mirena, ParaGard or CERVIX Breasts and hips respond to estradiol. So does the blood a woman loses with her menstrual period Implanon should carefully consider using condoms as well, to lining of the uterus. And the high level of estradiol A progesterone protecting her from anemia and pain 5 LH level of 3 ng/mL prevent infection. leads to that high level of LH that causes ovulation. is indicative of FSH ovulation Progestin-only pills (mini-pills) cause a thick cervical mucus; they D. Progesterone is the hormone that prepares the are much less likely than combined pills to stop ovulation from the 7 Myths: 100 pg lining of the uterus, the endometrium, for pregnancy. VAGINA ovaries. 1. Most women’s cycles are exactly 28 days. No, only One of the ways to determine whether ovulation has (C) Estradiol 12.8% 9 to 15% J of cycles are 28 days. About 20% of occured during a specific cycle (and that pregnancy Mirena IUD works primarily here causing a very thick cervical mucus women using Mirena stop having periods. could occur) is to measure the progesterone level. 2 4 6 8 10 12 14 16 18 19 20 22 24 26 28 Ejaculation of sperm happens here unless man uses a 2. IUDs cause . No, both Mirena and ParaGard IUDs If ovulation has happened, a woman’s progesterone In this diagram, the distance from the condom, withdrawal or vasectomy or a woman has a prevent fertilization, thus preventing both spontaneous abor- level has increased from zero or undetectable to (A) Menses (E) Ovulation opening of the cervix up to the top of the female condom or diaphragm in place. tions () and the need for induced abortions due above 3 ng/ml. uterine cavity measures 7.0 centimeters. to unintended pregnancies. Before having a baby, 70% of women 15-25 Spermicides - foam, film, gels, creams with a diaphragm, 3. Condoms are not effective at preventing sexually E. Ovulation occurs in some, but not all cycles. Do you have questions about all this? creams alone and sponges kill sperm Cycles without ovulation are most likely to occur in years of age have a uterus this large or transmitted infections. WRONG: According to the CDC, women who have just started to have periods and Get all the answers at larger. A uterus this size has adequate room Abstinence... just where does it work? It works between condoms are highly effective vs. STIs, providing an essentially in women 35 to 50 years old. Ovulation suppression www.managingcontraception.com for a Mirena or ParaGard IUD. the ears. That is, in the brain. But to be effective, it must also impermeable barrier to particles the size of STI pathogens. by Implanon is more profound than with any other work in the genital area, as well. It works if two partners have Women using the LARC methods, pills or rings­, should use current contraceptive. clearly communicated and agreed not to have sex. condoms, too! 4. Hormonal contraceptives cause cancer. Definitely means... Wrong! Pills prevent colon, ovary and endometrial cancer. Long Acting Reversible Contraceptives. There are now 3: the Implanon implant, the Mirena IUD and the ParaGard IUD. Pills do not increase a woman’s risk for . K L *LARC Mirena IUDs prevent endometrial hyperplasia and endome- Nexplanon & Implanon Implants Mirena IUD The Levonorgestrel Intrauterine Device ParaGard IUD The Copper T 380-A Intrauterine Device trial cancer. The Implant Mirena is placed into a woman’s uterus, where it is ParaGard is placed into a woman’s uterus, where it is effective for 10 to 12 years, 5. Women with fibroids cannot use a Mirena IUD. Implants are inserted under the skin, where they re- effective for 5 to 7 years, maybe longer. Mirena has so maybe longer. While causing increased bleeding and/or pain in the first several WRONG: In fact, Mirena IUDs decrease fibroid bleeding and, main effective for 3 to 4 years, maybe longer. Irregular many non-contraceptive benefits. It is used to prevent or months, in the long run, ParaGard has minimal effects on the physiology of a perhaps, fibroid size. spotting and bleeding improves over time. The total treat menstrual pain, menstrual blood loss, endometrial woman’s periods, including the likelihood of ovulation. ParaGard IUDs are, by far, the 6. Women cannot use an IUD until they have had a baby. days of bleeding a woman experiences are diminished cancer, uterine fibroids, endometriosis and dysfunctional most effective emergency contraception and may be inserted within 5 to 7 days of No, both the World Health Organization M and the Centers by Implanon. No women ovulate in the first 30 uterine bleeding (DUB). After the first year, 50 to 75% of unprotected sex. In a British study, not one of 1,963 women who received a for Disease Control (CDC) N consider the IUD an acceptable months of using an Implanon implant. women using Mirena IUDs are ovulating. ParaGard IUD for emergency contraception became pregnant. O choice for women who have not had a baby. IUDs do not cause pelvic infections or ectopic pregnancies. Adapted from CHOICES 2011 Hatcher, Rachel and Moynihan 1. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth Edition, p.102. 2. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth Edition, p.195. 3. Raymond, EG, Con- traceptive Implants. 4. Zieman M, et al, Managing Contraception 2010-2012. 5. Grimes DA, IN Hatcher, Trussell, et al, Contraceptive Technology 19th Ed., 2007: p. 147. 6. Fritz MA, Speroff L. Clinical Gynecologic Endocrinology and Infertility. Eighth Edition, p. 579. 7. Miller IM 7. IUDs are just too expensive. Well, they may cost lots, but, 15 Couthino EM, & Segal SJ, Is Menstruation Obsolete? 8. Westrom. 9. Vollmann RF 1967. 10. Speroff-Fritz 2001 p. 238. 11. Speroff & Darney 2001 A Clinical Guide for Contraception, 4th Edition. 12. WHO Collaborative Group Lancet 1996. 13. WHO MEC 2009. 14. CDC US MEC 2010. over time, IUDs are definitely the most cost effective revers- 16 15. Godfrey BJOG, 2010 ible contraceptives. Robert A. Hatcher MD, MPH and Sharon A. Rachel MA, MPH Choices and the Contraceptive Options Poster are produced by Bridging the Gap Communications. © 2012 To order, call 404-875-5001 or visit www.managingcontraception.com 12-19-11 Edit www.managingcontraception.com Can I get an IUD if I haven’t had a baby? Chapter According to the World Health Organization and the Centers for Disease Control, it is generally safe for IUDs women who have not had a baby to use the Copper T and Mirena® IUDs. Risk for expulsion of an IUD is 11 about 2% to 5%, regardless of whether or not a woman has had a baby already.

WHAT IS THE COPPER IUD (ParaGard®)? WHAT IS THE LEVONORGESTREL IUD (Mirena®)?

orldwide more women use intra-uterine devices (IUDs) than any other contraceptive, except sterilization! n IUD is a small device which is placed inside the uterus. The Mirena® IUD is T-shaped like WAn IUD is a small device which is placed inside the uterus. The copper IUD is a simple T-shaped piece of soft, theA copper IUD (ParaGard®). Mirena®’s vertical stem contains a progestin (hormone) called flexible plastic, wrapped with natural copper. The IUD has two very small strings that trail out through the cervix, levonorgestrel. This hormone is a progestin much like the progesterone a woman’s ovaries which allow the woman to check that the IUD is still in place and allows her clinician to remove the IUD when she produce each monthly cycle. The IUD slowly releases very small amounts of levonorgestrel chooses. Once the IUD is in place, the copper is slowly released into the uterine cavity. Copper stops sperm from directly into the uterus. The levonorgestrel causes the cervical mucus to become thicker making their way up through the uterus into the tubes, and it reduces the ability of sperm to fertilize the egg. An so sperm cannot reach the egg. Among average couples who use this IUD, one in 1,000 will experience an acci- IUD also prevents a fertilized egg from successfully implanting in the lining of the uterus if fertilization has oc- dental pregnancy in the first year. Seven in 1,000 women who keep the IUD in place for 5 years will get pregnant curred, though this is very rare. during that time. If left in place for 7 years the cumulative failure rate is 1.1%. Mirena® is as effective in prevent- Among couples who initiate use of this IUD, less than 1.0% will experience an accidental pregnancy in the ing pregnancy as tubal sterilization. Mirena® has been available for over 10 years in Europe and has been used by first year. Complete information about this contraceptive is available from your clinician or the package insert ac- over 2 million women worldwide. In Europe 10-25% of women use an IUD compared to 5% in the United States. companying the copper IUD. Mirena® is part of the reason for the popularity of the IUD in Europe. WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES?

8IUDs are the most effective reversible method of 8 There may be cramping, pain or spotting after 8A reversible method as effective as tubal sterilization! 8Do NOT start this method of birth birth control. insertion. 8Keeps hormone levels steadier and lower than the pill. control unless you will find it accept- 8The copper IUD is effective for at least 12 years. 8The number of bleeding days is slightly higher than able to have your periods change. 8It decreases menstrual cramping and dramatically decreases menstrual blood 8Only 2 out of 100 women using a copper IUD for 10 normal and you may have somewhat increased They WILL change a lot. loss (a 95% reduction in menstrual blood loss). Some women (about years will become pregnant. menstrual cramping. If your bleeding pattern is 20%) experience an absence of menstrual bleeding after one year. 8There may be more bleeding days than 8This contraceptive is very inexpensive when one bothersome to you, contact your clinician. There are normal for the first few months and medications which may give you a more acceptable 8This IUD may be left in place for at least 5 years, and is considers the long years of easy use that a woman gets less than normal after 6 to 8 months. pattern of bleeding and cramping. probably effective for 7 or more years. from it. In fact, over time, it becomes the cheapest (most If your bleeding pattern is bothersome, “cost effective”) of all the reversible contraceptives. 8This IUD provides no protection against sexually 8IUDs are safe, inexpensive over time, and provide extremely contact your clinician. There are transmitted infections. Use condoms if there is any risk. effective long-term contraception from a single decision. 8Use of an IUD is convenient, safe, and private. medications which can help you have a 8There is a high initial cost of insertion. However, 8One of the costs of any contraceptive is the cost to you should better pattern of bleeding. 8To “maintain” the IUD, all a woman has to do is check after 2 years, it is the most cost-effective of all your contraceptive fail. Given the extremely low failure rate of Mirena®, for the strings each month. Some clinicians say this is 8The IUD does not provide protection contraceptive methods. a person using this method is far less likely to have the emotional unnecessary and recommend only that women check against sexually transmitted infections. and financial expenses associated with an unintended pregnancy. their IUD strings several times after insertion. The 8The IUD must be inserted by a doctor, nurse Women using a Mirena® should use 8To “maintain” the IUD, all a woman has to do is check for the strings condoms if there is any risk of infection. copper IUD is one of the “you can’t forget me” methods! practitioner, nurse midwife or physician’s assistant who is trained in the insertion procedure. each month. Some clinicians say this is unnecessary and recommend 8The copper IUD may be used by women who 8There is a high initial cost of insertion. only that women check their IUD strings several times after cannot use estrogen-containing birth control such as 8A very small percentage of women are allergic to However, many clinics are able to insert insertion. Mirena® is one of the “you can’t forget me” methods! pills, patches or vaginal rings. copper. IUDs at a low cost or no cost through 8Once Mirena® is removed, a woman’s natural fertility returns a number of mechanisms (see “The 8The copper IUD may be inserted immediately following 8Some men can feel the IUD strings with their penis immediately. Most women who want to become pregnant will Incredible St. Louis Story” at the end of the delivery of a baby or immediately after an abortion. during intercourse. become pregnant in the first year after Mirena® is removed. this book). 8Some studies of IUDs have shown a decreased risk for 8Over time, the IUD becomes very inexpensive because there are no refills uterine cancer. There is also some evidence that IUDs of medications or supplies to buy month after month, year after year. protect against cervical cancer.

Where do I get an IUD? Where and When do I get a Mirena® IUD? You can get an IUD inserted by your doctor, nurse practitioner, nurse midwife or health department. Not all clini- Mirena® can be inserted by your clinician or at a Planned Parenthood or health department clinic. Most clinics cians insert IUDs. Check in advance. Most clinics insert IUDs when a woman has her period or within 7 days insert IUDs when a woman has her period or within 7 days of the start of the period. If there is no chance the after her period starts. If there is no chance the woman is pregnant, it may be possible to insert an IUD at other woman is pregnant, an IUD may be inserted at other times in the cycle. times.

17 18 www.managingcontraception.com www.managingcontraception.com Chapter ® Chapter 12 IMPLANON IMPLANT 13 EMERGENCY CONTRACEPTION

® WHAT IS THE IMPLANON IMPLANT? INSERTION OF A COPPER IUD Implanon® is a flexible 4 centimeter long rod with a core of a progestin called etonogestrel. The single Implanon® implant is placed under the skin of the upper arm with a disposable inserter. The progestin is released For up to 5 to 8 days after unprotected intercourse, you can have an intrauterine device slowly and Implanon® remains effective for 3 years. It provides a hormone much like the progesterone a woman (IUD) inserted to keep you from getting pregnant. This is the most effective currently available produces during the last 2 weeks of each monthly cycle. It stops the woman from releasing an egg and leads to a postcoital (after-sex) contraceptive in the United States. The copper IUD is inserted into the thick cervical mucus that prevents sperm from getting up through the cervical canal. Many clinics recommend that uterus and prevents implantation of a fertilized egg (if an egg was fertilized by the unprotected a backup contraceptive be used for 7 days after Implanon® is inserted. There were no pregnancies at all in the wom- sex). IUD insertion has a much lower failure rate than emergency contraception pills. Information about this emer- en participating in the clinical trials leading to approval of Implanon®. Complete information about this contracep- gency contraceptive is available from your clinician or by calling 1-888-NOT-2-LATE. Once in place, the IUD may be tive is available from your clinician or from the package insert that is provided when your implant is inserted. left in place as a woman’s ongoing contraceptive for up to 12 years.

If 1,000 women have an IUD inserted as emergency contraception after unprotected sex, only one will WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? become pregnant, while 1 in 100 women who use Plan B® as an emergency contraceptive become pregnant. Eight in 100 women become pregnant with no emergency contraception. 8The most effective reversible contraceptive ever 8Do NOT start this method of birth control unless developed. you will find it acceptable to have your periods 8Nothing needs to be taken daily or used at the time of change. They WILL change a lot. WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? sexual intercourse. Implanon® is one of the “you can’t 8Implanon® usually leads to irregular periods. If your forget me” methods! bleeding pattern is bothersome to you, it definitely 8Sex may be enjoyed more because of less fear of pregnancy. tends to get better over time. 8If 1,000 women have unprotected intercourse 8Not all clinicians insert IUDs. in the middle 2 weeks of their cycle, 80 would 8Implanon® is extremely effective in preventing 8Implanon® does not protect you from HIV or other 8Women may have some cramping or pain at the time infections. Use condoms if you are at risk. become pregnant without emergency of or just after insertion of the IUD. pregnancy. contraception, but only 1 will become pregnant 8Women lose less blood and have less cramping 8Allergic reactions may occur, though they are if a copper IUD is inserted as emergency 8There is a high initial cost of insertion ($500 to $800), during their periods. very rare. contraception. In one study, not one of 1,963 but this is far less expensive than a pregnancy or raising a child to age 18. If it is left in place, over time it 8Some women (about 15% at one year) stop bleeding 8Requires a physician or nurse practitioner who is women who received a copper T IUD for trained to insert and remove Implanon®. emergency contraception became pregnant. becomes the most cost-effective contraceptive completely. available. 8Implanon® is expensive in some healthcare settings. 8Once in place, this IUD can be used for up to 12 8Anemia (feeling tired from not having enough iron in 8If you leave the IUD in place, it may cause irregular your body) is rare. The cost is over $500 in private offices and just over years as an effective contraceptive. $250 in public sector clinics, but is less costly over periods or more cramping with periods. 8For women who have previously had painful periods, time than pills. 8IUDs offer no protection against STDs. Use a condom if about 88% will have less or no uterine pain and infection is a possibility. cramping after receiving Implanon®. 8Nursing mothers can receive Implanon®. According to the World Health Organization, it’s best to begin Where can I get an IUD inserted after unprotected sex? use after the baby is 6 weeks old, but most U.S. programs will insert Implanon® when a new You can go to your clinician or family planning clinic. Some clinicians are not familiar with emergency mother leaves the hospital after delivery. contraception. In this case, call the toll-free hotline: 1-888-NOT-2-LATE to obtain the phone numbers of 8Implanon® may improve PMS, depression and clinicians near you who may be willing to insert an emergency IUD. Some of these sources of help are free. symptoms from endometriosis. You can also go to www.not-2-late.com for additional information.

® Where can I go to get started using Implanon ? Can a Mirena® IUD be used for emergency contraception? To your doctor, nurse practitioner, physician assistant, health department or Planned Parenthood. Yes. However, the effectiveness of Mirena® as emergency contraception has not yet been proven. Therefore, a woman choosing Mirena® as an emergency contraceptive should use Plan B® as well.

19 20 EMERGENCY CONTRACEPTIVE PILLS (ECPs): ANOTHER LESS DESIRABLE APPROACH: MORNING AFTER PILLS – COMBINED ORAL CONTRACEPTIVE PILLS (COCs) omen who have access to combined estrogen/progestin birth control pills may use these pills as Best Approach: Plan B® Wemergency contraception. This approach is less effective and likely to cause more nausea and vomiting than the Plan B®, Plan B® One-Step and Next Choice® method. For some women, though, it may make the most sense. One-Step. One Pill Only. All Medication at Once. Here are instructions for using pills you may already have at home.

CPs (Plan B®, Plan B® One-Step, Next Choice®) are a form of emergency contraception that can prevent pregnancy Ovral®, Ogestrel®: Take 2 pills as soon as possible within 120 hours of unprotected intercourse and then 2 more pills 12 hours later. Eif taken within 120 hours (5 days) after unprotected sex. ECPs may be taken if a mistake is made using another method, if a couple forgets to use a contraceptive, or if a woman is forced to have sex. Plan B® One-Step is one Seasonale®, Seasonique®, Levlen®, Lo-Ovral®, Nordette®, Cryselle®, Low-Ogestrel®, Portia®, Levora®, 1.5 mg levonogestrel pill. The original Plan B® pills provide the same amount of levonogestrel in two tablets. These Enpresse®, Jolessa®, Quasense®, Tri-Leven®, Trivora®, or Tri-Phasil®: Take 4 pills as soon as possible within 120 hours of unprotected intercourse and 4 more pills 12 hours later. half-strength tablets may be taken together at the same time, as soon as possible after unprotected sex. All of these progestin-only contraceptive pills are available without a prescription to women and men 17 and older. They may be Alesse®, Aviane®, Lessina®, Levlite®, Lo-Seasonique®, Lutera®, Sronyx®: Take 5 pills as soon as possible within 120 used by women 16 and under with a prescription. ECPs should be taken as soon as possible after unprotected sex! hours of unprotected intercourse, and 5 more pills 12 hours later. Lybrel®: Take 6 pills as soon as possible within 120 hours of unprotected intercourse, and 6 more pills 12 hours later. WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES?

8ECPs provide an important safety net for women whose 8ECPs are not a substitute for correct use of Overview of Postcoital Methods Currently Available in the U.S. regular contraceptive method may have failed (for regular contraceptives. It is safe to use example, if a condom broke or fell off), or for women who emergency contraceptive pills more than once. POPs (Progestin-Only COCs (Combined Oral may have had sex without contraception. It is definitely preferable to find an ongoing CHARACTERISTIC Pills like Plan B Contraceptives) Copper IUD method of contraception that you will use 8The Plan B®, Plan B® One-Step and Next Choice® regimens Timing of initiation ASAP but can be used up to ASAP but can be used up to Up to 8 days after consistently and correctly. are all highly effective, reducing the average risk of after intercourse 120 hours (5 days) after unpro- 4 & 5 days after unprotected unprotected sex pregnancy among users from about 8% to about 1%. If 8Possible side effects are nausea (about 25%), tected sex – sooner is better! sex – sooner is better taken in the first 24 hours afterintercourse, ECPs reduce the vomiting (about 10%), lower abdominal risk of pregnancy by 89%. pain, fatigue, headache, dizziness, breast Pregnancies/100 Early start: 0.4% (less than Early start: 0.5% (less than 0.1% women (Percent 12 hours after sex) 12 hours after sex) 8Plan B®, Plan B® One-Step and Next Choice®’s levonorgestrel- tenderness, and menstrual changes. of women who will Late start: 2.7% (1-3 days) Late start: 4.2% (1-3 days) only regimen is much better tolerated than older emergency 8After taking ECPs, your next period may be become pregnant) Average: 1.1% Average: 2 – 3.2% contraception regimens. (These older forms combined early, on time, or late. ethinyl estradiol (estrogen) plus norgestrel or levonorgestrel. 8No protection against sexually transmitted Advantages Fewer side effects than COCs; Wide range of COCs May be inserted 5 or more There is information on the next page about these methods.) infections. Available without a prescrip- available for use days after intercourse, but 8There are no scientific data to suggest that there would be an tion for women and men 17 before implantation. Effective increased risk of birth defects or miscarriage if ECPs fail or if a and older. Both pills can be long-term contraceptive for woman who is already pregnant takes them. taken at once. appropriate women. Disadvantages May be less available than Gastrointestinal side effects May be expensive. Woman must Where can I get Plan B®, Plan B® One-Step and Next Choice®? the COCs for some women. (nausea and vomiting) – can be appropriate for IUD. More Prescription required for be reduced with anti-nau- careful counseling between Plan B®, Plan B® One-Step and Next Choice® can be provided through advance prescription, prescription by women 16 and under – check sea treatment. Prescription woman and clinician – must telephone, walk-in prescription, or an office visit for women 16 and younger. Women and men 17 and older can pharmacy for availability. required if woman does not consider timing, STI testing, etc. purchase Plan B®, Plan B® One-Step and Next Choice® from pharmacies without a prescription. A pelvic exami- have the pills already Insertion procedure required. nation or a pregnancy test is NOT required before treatment. Some clinicians are not familiar with emergency Side effects Spotting. Same hormonal Nausea, vomiting, spotting, All women have some pelvic pain contraception. In this case, call the toll-free hotline, 1-888-NOT-2-LATE. This hotline also provides information side effects as COCs, but less headache, breast tenderness, and vaginal bleeding. This may about other emergency contraceptive options. In planning for emergency contraceptive services, it is important frequent and less severe moodiness, change in next be worse or last longer for some to keep in mind that the sooner ECPs are taken after unprotected intercourse, the more effective they are. menses women. IUD may be expelled (pushed out) by uterus and need When should I start taking birth control pills again after I’ve taken ECPs? to be replaced (this is rare). If your primary contraceptive method is pills (COCs, POPs) and you miss several COCs or even one POP, Avoid use in preg- Do not use in women with Do not use in women with Prescribing precautions for you should take Plan B®, Plan B® One-Step or Next Choice® ASAP within 5 days (120 hours) after you’ve had nant women and known pregnancy because the known pregnancy or current IUD use unprotected intercourse. The day after you take ECPs, start taking your pills again from where you left off. women with other treatment will not be effective. severe migraine. POPs a There is no need to take several pills at once to “make up” for missed pills. prescribing precau- Will not cause birth defects if better option for all women tions taken by a pregnant woman. with a history of blood clots.

21 22 www.managingcontraception.com ADVANTAGES (continued) DISADVANTAGES (continued)

Chapter ® 8Depo-Provera® may lower your estrogen level and DEPO-PROVERA INJECTIONS 8It’s OK to start a new contraceptive if fewer than just how important this is in causing bone loss is still 14 13 weeks have passed since the last shot. unclear. Talk to your clinician about this. Get 8Depo-Provera® may improve premenstrual regular exercise and take extra calcium to protect syndrome (PMS), depression and symptoms your bones from osteoporosis. Bone mass returns to from endometriosis (menstrual blood and tissue normal after Depo-Provera® use ends. building up outside of the uterus). 8A few women are allergic to Depo-Provera®. Allergic reactions are very rare, but they occur, and WHAT ARE BIRTH CONTROL SHOTS? 8Can prevent sickle cell crises and certain kinds of seizures. the effects of the shot cannot be stopped once it is given. Such a woman may need anti-allergy 8Unlike combined pills, Depo-Provera® does not medicine for several days to months. epo-Provera® is administered once every three months. It provides a hormone much like the progesterone lose effectiveness if you take medicines that aD woman produces during the last 2 weeks of each monthly cycle. It stops the woman from releasing an egg and affect the liver. 8Depo-Provera® may be expensive in some clinics or doctors’ offices. provides other contraceptive effects. Many clinics recommend use of a backup contraceptive for a week after the 8Decreased risk for cancers of the ovaries and first shot. Among average couples who start using Depo-Provera®, about 3 in 100 will have an unintended preg- lining of the uterus (endometrial cancer). 8Increase in LDL (bad cholesterol) and decrease in nancy in the first year. If Depo-Provera® injections are used correctly and on schedule, just 3 in 1,000 women will HDL (good cholesterol) has been found in some become pregnant in the first year of use. The difference between average and “perfect” users has to do with some studies. women being pregnant already when the first shot is given (this won’t harm the fetus or disrupt the pregnancy) and with some women being too late for the follow-up shots or simply never coming back for follow-up shots. Complete information about this contraceptive is available from your clinician or from the package insert that is ® provided with Depo-Provera® injections. WHERE CAN I GO TO GET STARTED USING DEPO-PROVERA SHOTS?

WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? See your doctor, nurse practitioner, physician assistant, health department or Planned Parenthood to get Depo- Provera® as an intramuscular injection. Subcutaneous injections (shallower injections, just under the skin) are 8Nothing needs to be taken daily or used at the 8Many women stop using Depo-Provera® for a variety also available so that women can give themselves Depo-Provera® injections at home. This gives the same level of time of sex. of reasons. In fact, only 30 – 60% of women contraceptive protection as the other type of injection. Ask your clinician if this is right for you. 8Depo-Provera® is extremely effective. If women continue to use Depo-Provera® after the first year. receive their injections right on time (every 3 8Do NOT start this method of birth control unless you months or 13 weeks), only 3 women in 1,000 will will find it acceptable to have your periods change. The World Health Organization now says that Depo-Provera® injections work for 13 plus 4 weeks and that become pregnant in the course of one year. They WILL change a lot. women returning 4 weeks LATE for their 3 month (13 weeks) injection may receive their next shot that day. 8Women, including women with fibroids (growths 8Depo-Provera® injections lead to very irregular in the muscle of the uterus), lose less blood periods. If your bleeding pattern is bothersome to using Depo-Provera® and have less menstrual you, you can take medications which may give you a cramping. Often after 3 injections women stop more acceptable pattern of bleeding. having periods. This is safe! 8Some women gain weight. To avoid weight gain, Choices was written by Bob Hatcher, 8Decreased risk of anemia (feeling tired from not watch your calories and get lots of exercise. Sharon Rachel, and Aimee Moynihan, having enough iron in your body). 8Depo-Provera® does not protect against HIV or 8Privacy is a major advantage. No one has to other sexually transmitted infections. Use condoms but help came from several others: Peter know you are using this method. if you are at risk. 8Sex may be enjoyed more because of less fear of 8You must have a new injection every three months. Hatcher is a family practice physician pregnancy. 8Depression and premenstrual symptoms may from Portland, Oregon. John Stanley 8Breastfeeding mothers can receive Depo- become worse. Provera® injections. Most U.S. programs will 8It may be a number of months before your periods Sharon Bob Aimee is the backbone of the company that provide Depo-Provera® when a nursing mother return to normal after your last shot. It takes an Rachel Hatcher Moynihan produces Choices, The Bridging the Gap leaves the hospital after delivery. average of 10 months for fertility to return after the last shot, making it hard to plan pregnancy exactly. Foundation. Anna Handler, Anne Rappaport and Amy Winter are recent grads of The Rollins School of Public Health at Emory and are such outstanding young women. 23 24 www.managingcontraception.com Progestin-Only Pills (POPs) (Mini-Pills) Chapter 15 PILLS WHAT ARE PROGESTIN-ONLY PILLS (POPs)? Combined Oral Contraceptive Pills One pill every day: All the pills are the same color and the same hormone. NO PLACEBO PILLS. NO ESTROGEN IN PILLS.

Happy 50th Birthday!!! Birth control pills were approved in June of 1960. About 80% of U.S. women have Progestin-only pills (or mini-pills) contain just one hormone – the progestin, norethindrone. A cycle does taken pills sometime in their lives by the time they reach menopause. not have hormone-free days or placebo pills. When you take the last pill from one package of POPs, you start the next package the very next day (NO DAYS OFF). They work by making cervical mucus thicker so sperm cannot WHAT ARE COMBINED BIRTH CONTROL PILLS? reach the egg, and by making the lining of the uterus thinner. Sometimes they stop ovulation (release of an egg). Among average couples who use progestin-only pills, about 8% will have an accidental pregnancy in the Combined birth control pills contain two hormones – estrogen and progestin. They work by stopping ovulation (release first year. This is because some women do not take their pills correctly. To take POPs correctly, a woman takes of an egg) and by making the lining of the uterus thinner. Among typical couples who initiate use of combined pills about one pill at the same time every day. If these pills are used consistently and correctly, just 3 out of 1,000 women 8% (1 in 12) will experience an accidental pregnancy in the first year. This is because sometimes pills are not used correctly. will become pregnant over the course of a year. Complete information about this contraceptive is available from If pills are used consistently and correctly, just three in 1,000 women will become pregnant in the first year of pill use. your clinician or the package insert accompanying the specific pills you are taking. Use a backup contraceptive for the first 7 days of your first pack of pills. You do not need to use a backup method during the hormone-free days of your pill pack. Complete information about this contraceptive is available from your clinician or the WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? package insert accompanying the specific pill brand you are taking. READ YOUR PACKAGE INSERT CAREFULLY. 8There are no estrogen side effects. POPs can be taken by 8Do NOT start this method of birth control WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? some women who have had side effects or complications unless you will find it acceptable to have your using estrogen-containing pills or other contraceptives. periods change. They WILL change a lot. 8Pills decrease women’s menstrual cramps, pain, and blood loss. 8Pills do not protect you from HIV or 8The amount of the progestin in POPs is less than in combined pills. 8Menstrual irregularity is the most common 8Pills reduce menstrual blood loss and can prevent or help treat anemia. other infections. Use a condom if you may be at risk. 8Mini-pills are also easier to take than combined pills. problem with mini-pills. While the amount of 8Acne often improves, and hair growth on the face is reduced. blood lost is less, bleeding may be at irregular 8You have to remember to take the pill You take exactly the same kind of pill every single day. 8Many women enjoy sex more when on pills because of decreased intervals and there may be spotting between at the same time every day. 8Breastfeeding mothers can take progestin-only pills. fear of pregnancy. periods. 8You may have nausea and/or spotting Nursing moms who find that they like POPs may continue 8You can control the cycle so as not to have your period during certain 8Mini-pills tend to make periods very short and (mostly during the first few cycles on pills). on them indefinitely. times (vacation, sporting events, backpacking, exams, honeymoon, etc.) scanty. You may go several months with no 8The pill may cause headaches, 8There are decreased cramps and pain during periods. 8You can decrease the number of periods by using Seasonale® or bleeding at all. (Some women go years without depression, anxiety, fatigue, mood There may also be decreased pain at the time of ovulation. Seasonique® (84 pills with hormones followed by 3-7 pills without a period and love it!) changes, or decreased enjoyment of 8Mini-pills can be taken by women who have had any hormones) or Lybrel® (365 hormonal pills and no hormone-free days). 8You have to remember to take a pill every single sex in some women. of several types of blood clots. 8All pill users who are using “non-cyclic” pills (same dose of hormones day at the same time. Staying on schedule is 8A backup contraceptive is required 8In some women, cloasma (the “mask of pregnancy” – in all the pills) have the option of spacing their periods out. A woman important because progestin-only pills cause for 7 days if you have any question increased facial pigmentation due to sun exposure) is caused with long, painful or heavy periods or periods which bring on headaches cervical mucus to thicken for only about 22-24 about how many pills you have by the estrogen in combined pills and therefore progestin- or other problems may choose to do this. She can do this by taking hours. missed. The pill is easy to forget, but only pills maybe be preferable for women with this problem. the active hormone pills continuously. She can time her bleeding to 8Progestin-only pills do not protect you from so important to remember! come every 2, 6 or 12 or more months. The bleeding comes when she 8Mini-pills can be taken by women who smoke and are over 35. HIV or other sexually transmitted infections. takes a few days off the active hormone pills. This is safe. 8Serious complications like blood clots 8A woman on mini-pills may experience fewer headaches Use a condom if you or your partner may be and strokes may occur but are rare. 8Pills greatly decrease a woman’s risk for cancers of the ovaries and than she had on combined pills. at risk. endometrium (lining of the uterus). They also lower your chances of 8Pills can be quite expensive and require a prescription. having benign breast masses (breast masses which are NOT cancer), Where do I get Mini-Pills? ovarian cysts, endometriosis, and pelvic inflammatory disease (PID). 8Pills may lead to higher rates of one In the United States you need a prescription. You can get a prescription for mini-pills from your clinician, health 8Fertility in women who have used pills is actually improved. WHY? Because type of cervical cancer. department, or family planning clinic. Most, but not all, pharmacies carry progestin only pills. Call the pharmacy pills decrease and are used to treat endometriosis and polycystic ovarian 8After stopping pills, you may not get syndrome (PCOS). Pills help prevent pelvic inflammatory disease. your period for 1-3 months, although first. Mini-pills tend to cost more than combined birth control pills. this is rare. Do birth control pills cause breast cancer? Where can I get Pills? There is no evidence to indicate that taking birth control pills will cause a woman to develop breast cancer. However, since breast cancer is estrogen-dependent, if a woman who takes birth control pills develops breast cancer, she should In the United States you need a prescription. You can get pills from your doctor, nurse practitioner, nurse midwife, physician’s stop taking pills immediately, consider a progestin-only or non-hormonal contraceptive, and begin cancer treatment. assistant, health department, family planning clinic or from your school or college health center. As of 2009 most pills cost $45 to $75 per 28 day cycle, without insurance. Sprintec and TriSprintec are available at Walmart, Kroger and Target for $9 per cycle. 25 26 www.managingcontraception.com www.managingcontraception.com

Chapter ® Chapter ® 16 PATCHES Ortho Evra 17 RINGS NuvaRing Contraceptive Patches Vaginal Contraceptive Rings

WHAT IS “THE PATCH”? HOW IS NuvaRing® USED FOR CONTRACEPTION? rtho Evra® is a small that sticks to a woman’s skin (like a band-aid) and delivers both an es- trogenO and a progestin through the skin into her bloodstream, which stops ovulation. One patch is worn each week for ne soft, flexible, 2-inch diameter ring is placed in the vagina near the cervix and is left in place for 21 days. It is 3 weeks in a row, usually on the lower abdomen, buttocks, upper outer arm, upper back or upper torso (except for the Othen removed and the next 7 days are ring-free to permit the woman to have a period. The ring delivers both estro- breasts). The fourth week is patch-free. During this week, the woman has a withdrawal bleed (like a period). gen and progestin, which stops ovulation. Used correctly and consistently the patch leads to only 3 pregnancies among 1,000 women using patches for a Used correctly and consistently the ring leads to only 3 pregnancies among 1,000 women using the ring for year! We don’t know yet what pregnancy (failure) rates are for average users who start the patch, but it is presumed that one year! Among average users, about 8 in 100 couples will have an unintended pregnancy in the first year. You do they are similar to pills at 8% (8 pregnancies in 100 women in the first year). You do not need a back-up method like not need a back-up method during the seven ring-free days. Complete information about this method is available condoms, abstinence or outercourse during the 7 patch-free days. Complete information about this method is avail- through your clinician and through the NuvaRing® package insert. It may help to have your clinician show you how able through your clinician and through the patch package insert. READ YOUR PACKAGE INSERT CAREFULLY! to insert and remove a ring, though most women have no problem at all putting in and removing their NuvaRing®. Ortho Evra® patches lead to slightly higher estrogen going into the woman’s body than pills or vaginal contra- It is generally recommended that the ring NOT be removed at the time of intercourse. READ YOUR PACKAGE ceptive rings. Whether this leads to slightly higher risks for women using patches is not clear. INSERT CAREFULLY!

WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES? WHAT ARE THE ADVANTAGES? WHAT ARE THE DISADVANTAGES?

8You don’t have to take a pill daily or 8The patch appears to be less effective for women weighing more 8You don’t have to take a pill daily or interrupt sex 8Rings do not protect you from HIV or other infections. interrupt sex (as you would with a barrier than 198 pounds (90 kg). The patch should not be a “first line” (as you would with a barrier contraceptive). Once Use condoms if you may be at risk. contraceptive). method without a backup for women weighing more than in place, the ring remains effective for a full four 8You may have spotting (mostly during the first few 8Patches decrease a woman’s menstrual 198 pounds. weeks (28 to 31 days). cycles using rings). cramps and pain. 8Patches do not protect against HIV or other infections. 8Rings decrease a woman’s menstrual cramps and 8Using NuvaRing® may cause headaches, depression, 8Patches decrease the amount of menstrual Use condoms if you may be at risk. pain. mood changes, or decreased enjoyment of sex (these bleeding and a woman’s risk for anemia. 8You may have spotting or irregular bleeding (mostly during the 8Rings decrease the amount of menstrual bleeding side effects occur infrequently). 8Acne may improve and facial hair is first few cycles). and a woman’s risk for anemia. 8Serious complications such as blood clots may occur diminished. 8Using patches may cause headaches, depression, mood changes, 8Acne may improve and facial hair is reduced. but are rare. 8Many women enjoy sex more when using or decreased enjoyment of sex (these side effects are infrequent). 8There is very little weight gain for those who use 8Rings cost about $40 per month without insurance or Ortha Evra® patches because of decreased 8Serious complications such as blood clots may occur but are rare. the ring. $480 per year. (Much less expensive at public clinics.) fear of pregnancy. 8Patches tend to be slightly more expensive than birth control pills. 8Many women enjoy sex more when using 8A back-up contraceptive for 7 days is recommended 8Each patch has enough hormones to In early 2010 the cost of patches for one 28 day cycle is $38 to $45 NuvaRing® because of decreased fear of if there is any question about starting the use of a suppress ovulation for up to 9 days, so you in most pharmacies. This works out to $494 to $585 per year! pregnancy. new ring on time. can be a day or so late putting on the next 8Partial detachment of patches (about 3%), complete detachment 8You can use rings for an extended period of time 8Some women are not comfortable touching their patch, but this is not recommended. (about 2%) and skin irritation may occur. Even less common or continuously (with no hormone-free intervals). vagina. 8When put on correctly, a woman can (under 1%) is increased pigmentation (change in color) of the 8Each ring has enough hormones to suppress 8CREATIVITY: Women have used tampon applicators exercise, shower, swim or go in a sauna or skin under the patch. This may last for a number of months. ovulation for up to 35 days, so you can be a to insert NuvaRings. hot tub and it still sticks 98% of the time 8If patch falls off, replace it as soon as you notice it’s gone. number of days late putting in a new ring. (check to make sure it’s still on!) 8A back-up contraceptive for 9 days is recommended if there 8The dose of estrogen is lower in NuvaRing® than is any question about starting use of a new patch late (more in the pill and the patch. than 7 days after removing the last patch), or if there is a question about the attachment of the patch. Where can I get NuvaRing®? Where can I get Ortho Evra® Patches? You will need a prescription from your nurse practitioner, physician, nurse midwife or physician’s assistant. You will need a prescription from your nurse practitioner, physician, nurse midwife or physician’s assistant. 27 28 CHOICES at Your Fingertips Hatcher, Rachel, S.A., and R.A., Moynihan, A.M. (2011). Choices (also “Outercourse”) (also Fertility Awareness with Diaphragm Film, Foam,Film, Gel Condoms: Male Breastfeeding Dual MethodDual Female (FC Spermicides: Copper IUD Copper

www.managingcontraception.com Withdrawal Abstinence (Paragard Condoms: Method Method Sponge Chapter ® ) ® 18 STERILIZATION ) No contact sexual on from entering vagina struating, <6 months sperm fromsperm entering from entering uterus Spermicides kill and kill Spermicides Periodic abstinence: sponge block sperm woman’s days fertile Woman exclusively vagina stops sperm inhibits ascent into Inhibits and sperm Fewer or no sperm Hormonal method Hormonal method immobilize sperm, Plastic sac wornPlastic sac in (condom) protects thane sheath worn vagina, preventing ovulating or men- tubal motility and breastfeeding, not Latex or polyure - No enters sperm against infection pregnancy while over stops penis protects against barrier method method barrier diaphragm and fallopian tubes How it Works post-partum enter vagina Tubal Sterilization fertilization vagina Before genital contact, Before genital contact, open end hangs out of before any ejaculation to base ofto base erect penis, prolactin and inhibits Clinician inserts IUD Clinician inserts diaphragm or sponge roll condom from tip cervical mucus, basal cervical from woman’s vagina vagina. Remove after Use pills/patch/ring/ remove immediately estrogen to suppress Woman tracks cycle Man removes penis Avoid any intimate Place spermicides, Place spermicides, body temperature,body Suckling produces timing and checks shot/implant/IUD into uterus, in left with condoms for insert closed end, closed insert in vagina prior to contact semen so place 10-12 years each act ofeach act inter does notdoes contact after ejaculation hormonal surge hormonal How to U sexual contactsexual ejaculation. ovulation vagina course se Itse

WHAT IS A TUBAL STERILIZATION? - Only used at time of intercourse,of time at used Only Beneficial to infant, Beneficial post-partum mone-free, may risk for decrease contraception, no other supplies Extremely effective, long-acting, can enhance foreplay, is less sex peace of mindpeace knowing you are Dual protectionDual for preven the - partners will not con male will partners use - Good choice forGood women whose body, works well for planning safe, convenient, private, hor alternative to condoms, adds tion of pregnancy and STDs; mother, may protect against improve self-esteem, highly less messy, involves man in uterine and cervical cancer uterine and cervical weight loss, pleasurable for prescription good needed, relationship-building, can Woman learns about her encourage creativity and Free, available to can all, Always available, is sex ubal sterilization is an operation which blocks the fallopian tubes from carrying a woman’s egg to her uterus. This is the Woman-controlled, no STD P STD P STD P STD P T lubrication to vagina extra protectedextra most commonly used method of birth control worldwide. After one of these operations a woman’s eggs will have no way to forneeded use some cancers Advantages pregnancy effective, R R R R messy get to her uterus, and the man’s sperm will have no way to get to the egg. All tubal sterilization operations should be consid- doms, OTECTION OTECTION OTECTION OTECTION ered permanent. A woman must be certain she does not want to have any more children and will not change her mind. . Tiger, Bridging Georgia: The Gap Foundation. WHERE CAN A WOMAN GET THIS OPERATION?

Some clinicians perform this operation; others do not. A woman can get a referral to a clinician who does the - keeping, live sperm 3-5 days High failure typical use rate, must know how to correctly Must pay for more than one and removal, more bleeding Difficult to for use Difficult irregular fertility, less after effective 6 use, man may erection, lose difficult, may frustrating difficult, be effective, can irritate vagina can decrease both partners’can both decrease Cramping during insertion months, breast discomfort use condomsuse and another NO STD P NO STD P NO STD P NO STD P NO STD P

tubal sterilization operation from her primary care clinician, health department, family planning clinic or local availability, some women noise during limited sex, practice learning how to Must have backup if any method ofmethod control; birth uncomfortable touching Unpredictable return of Sponge no longer being communication can be May disrupt must sex, possible latex allergies sexual contact sexual occurs, cycles, carefulcycles, record- days, cost. initial high prescription, not very produced, diaphragm Odd-looking, makes Odd-looking, medical society, or call Engender Health, the national organization involved in sterilization training and service requires fitting and sexual pleasuresexual Disadvantages inside uterus at (212) 561-8000 or email [email protected]. vaginastheir method R R R R R OTECTION OTECTION OTECTION OTECTION OTECTION

Vasectomy: “Makes a vast difference in your vas deferens” clinics, other retail Requires excellent Condoms at drug prescription only prescription women’s clinics, Gel: drugstores,Gel: stores, pharma - method bymethod pre - cies; Hormonal Sponge: online stores, online professionals Inserted and Everywhere, Everywhere, counsel new Drug stores,Drug Drug stores,Drug pharmacies, pharmacies, Availability Film/Foam/ Diaphragm: removed by all the time the all all the time the all counseling clinician. scription mothers Health online

WHAT IS A VASECTOMY? Other method Other Polyurethene: $400-$1,000 Film/Foam/ asectomy, or male sterilization, is the operation which blocks the tubes (called the vas deferens) that carry a Diaphragm: $1-$3 each Sponge: $3 $1-$3 each Condoms <$1 each <$1 each $10-$15 NONE NONE NONE NONE Varies V Latex: Cost Gel: man’s sperm to the outside. A man can still ejaculate but there isn’t any sperm in the fluid. This operation should be $55 considered permanent. A man should be certain he wants no more children and will not change his mind. Although vasectomy is safer, more effective and less invasive than tubal sterilization, as of the mid-2000s, there are only 4 nations in the world where exceed tubal sterilizations: Great Britain, the Netherlands, New Zealand and Bhutan. Unknown, though Typical: unknown highly effective highly Perfect: 0.5% Typical: 15% Typical: 27% Typical: 21% Typical: 25% Typical: 2% Perfect: 2% Perfect: 4% Perfect: 0% Perfect: 5% Failure % Failure 13%-29% 6%-15% Typical: Typical: Perfect: Perfect: Perfect: 1%-9% Once a man and a woman have all the children they want, it is time for the man to stand up and be counted. 0.6% 0.8% By this time the woman has purchased and used most of the contraceptives, dealt with any side effects or complications from contraceptives, carried and delivered all their children and breast fed all their babies (if that was her choice). Now is the time for the man to do his part. If he does she will appreciate him a lot.

Sharon A. Rachel, MA, MPH (2011) 29 30 www.managingcontraception.com Adolescent pregnancy prevention initiatives Not of method contraception individuals of a particular all use who all advantages the experience will and disadvantages listed above. Contraception (EC): Progestin-OnlyPills Levonorgestral IUD (POPs,“mini-pills”) Female Sterilization

support teens as they explore and determine Implanon Male Sterilization Combined Oral Oral Combined Contraceptives Depo-Provera Plan B® pills, Copper IUD Copper Ortho Evra Ortho (vasectomy) Emergency NuvaRing COMPARING TYPICAL EFFECTIVENESS OF (Mirena Injection responsible sexual and reproductive options Method Patch: Ring: Pills: ® for their future. Implant CONTRACEPTIVE METHODS ® ) ® ®

This book is designed to give YOU the power ® More effective How to make your Less than 1 pregnancy per method most effective mucus, endome thin - Suppresses ovulation, cervical mucus, thins cervical suppresses ovulation, tion, thicken cervical tion, thicken cervical therefore can - sperm Single rod implanted Pills thicken cervical Pills thicken cervical

Pills suppress ovula - 100 women in one year trium, may suppress No in semen, sperm Adhesive patch sup - Prevents pregnancy mucus, thins endo - mucus, thins endo - tube to prevent fer mucus, endo - thin Progestin thickens through Fallopian presses ovulation, presses ovulation, Stops passage egg sup - after unprotected thickens cervical thickens cervical thickens cervical thickens cervical thickens cervical thickens cervical thickens cervical thickens cervical to make good choices!not enter vagina We respect your right How it Works endometrium endometrium endometrium mucus, thins mucus, thins intercourse ovulation tilization metrium metrium to be responsible. metrium After procedure, little or nothing to do or remember.

Implanon & Nexplanon ParaGard Mirena Vasectomy: Use another method for first 3 Implants IUDs months and until there are no motile sperm Sex has - consequences. on 2 semen analyses. place for intercourse. buttocks 11-13 every IUD into uterus, left same time every day same every time woman’s upper arm, Injected into arm or procedure removes, part ofpart vas deferens left in place 3 yearsleft procedure removes Take one pill at the hormone-free days time every day (24 every time Provider implants week for 3 weeks, rod under skin of in place 5-7 years Wear 1 patch per blocks of off part within 120 hours days, 7 days then and or ties burns (5 days) after sex ring-free. Left in ring-free. Left Wear ring for 21 exactly the same the exactly Clinician inserts Clinician inserts Take pills ASAP, hours apart), no ties, orties, burns or Injections: Get repeat injections on time Take one pill at Fallopian tube How to u then 1 weekthen Outpatient Outpatient

Teens who are sexually active andpatch-free choose not

weeks Pills: Take a pill each day to use any method of birth control have a 90% 6 to 12 pregnancies per 100 women in one year chance of having to deal with a pregnancy It se Patch, Ring: Keep in place, change on time Condom, Diaphragm: Use correctly every within the first year of becoming sexually single time you have sex ovarian and endometrial cancers stay in place up to 12 years, Plan Safer, less expensive, more- effec lowers risk of , no lowest estrogen of dose any hor Extremely effective, long-acting, cycles, decreased risk of decreased cycles, ovarian Changed just once a week, stays B® available without a prescrip - cramps, acne, risk of decreased take ortake do daily, less menstrual Less orLess bleeding, no menstrual regular men - decreased cycles, safe, convenient, private, up to permanent changes menstrual cramps, acne, anemia; regular monal regular method, cycles Prevents pregnancy if regular Permanent. No risk of sexual tive than female sterilization. contraception fails, IUD can Changed just once a month, 90% reduction in menstrual Permanent, effective, highly on in water and if sweating,

active. Highly effective, nothing to reduced cramps, menstrual Fertility-awareness based methods: Ab- endometriosis symptoms Less menstrual bleeding, menstrual Less and endometrial cancers blood loss, cost-effective blood Extremely effective, less menstrual bleeding andmenstrual tion for women over 16

bleeding and cramping Withdrawal

cramping, improves (No deposit, stain or use condoms on fertile days. Newest Teen pregnancy costs taxpayers millions of No return) methods (Standard Days Method and Two Day strual crampsstrual dysfunction. Almost 50% of teens have never Advantages Method) mat be easier to use and consequent- dollars each year. ly more effective. considered how a pregnancy would The costs to the children born to teen parents Withdrawal, Spermicide: Use correctly every affect their lives or the lives of those time you have sex. is immeasurable. Less effective around them. THINK about it! 18 or more pregnancies per Adapted from WHO 2007 and Contraceptive Technology, 100 women in one year 20th Edition. Fertility-awareness Spermicides - The fact is, babies born to teens often do not based methods during and insertion removal, Not reversed, easily increased less effective in obese womenless in obese effective

common in younger women) Girls who have babies as teens often must by inserted provider, be tenderness, risks in smokers tenderness, risks in smokers risk of if Cramping during insertion regret and chronic paid are removing ring from vagina Spotting, irregular periods, Increased spotting initially, must daily, taken be mood tenderness, skin irritation, Not immediately effective, method fails, method regret (more Irregular bleeding, weight NO STD P NO STD P NO STD P NO STD P NO STD P NO STD P NO STD P NO STD P NO STD P NO STD P bleeding, high initial cost initial bleeding, high may dislike and inserting Nausea from pills, affects menstrual bleeding, IUD menstrual Spotting changes , mood rare, not reversed. easily Discomfort or bruising receive the support they need to grow and changes, nausea, breast and removal, irregular Mood changes, breast mood changes,mood breast

raise changesgain, mood those children in poverty, alone irregular bleeding, develop as well as babies born to adult parents. and dependent on the welfare system.Disadvantages r r r r r r r r r r OTECTION OTECTION OTECTION OTECTION OTECTION OTECTION OTECTION OTECTION OTECTION OTECTION The Incredible St. Louis Story 80% of the fathers of babies born to teens choose to live apart from their children and pay less than $800 a

year ininjected by provider child support. performed atperformed clinic performed atperformed clinic Surgical procedure Surgical procedure pharmacies, wom- pharmacies, wom- pharmacies, wom - pharmacies, wom - in clinic or patient Prescription only: Prescription only: Prescription only: Prescription only: Prescription only: IUD inserted byIUD inserted not-2-late.com

OTC >17 yrs >17 OTC 8 Inserted and Inserted and Availability removed by

removed by 10,000 women are being given contraceptives at no cost through Washington University in St. Louis en’s clinics en’s clinics en’s clinics en’s clinics clinician. clinician, clinician at home Teen pregnancyPlan B® is preventable! You only only don’t have to change YOUR life plan– 8 47.1% are choosing to use a Mirena* IUD (the levonorgestrel IUD) and 10.5% are choosing a if you have a PLAN for life. ParaGard IUD (the copper T IUD) - Simply amazing! $60/ injection $1000- $2500 8 $400-$1,000 11% are having an Implanon implant inserted. $300-$1000 There is a family planning provider $250-$550 per cycle per per cycle per per cycle per per cycle per per dose per $38-$45 $20-$40 $35-$80 $35-$90 $35-$80 in most U.S. counties where you Cost 8 can receive counseling, guidance IUDs and implants are the “you can’t forget me” methods. Almost 70% of women are choosing one of these three methods. and birth control, FREE and Prevents up to 80% depending method on of pregnancies that would otherwise would otherwise Typical/ Perfect Typical/Perfect: Typical/Perfect Typical: 0.15% have occurred Perfect: 0.3% Perfect: 0.3% Perfect: 0.3% Perfect: 0.1% Perfect: 0.3% Perfect: 0.3% Typical: 8% Typical: 8% Typical: 8% Typical: 8% confidentially!Typical: 3% * Terri Wynn-Hipps is a nurse midwife in Ft. Bragg, NC. She has inserted about 200 IUDs in the past year. 85% of 0.8%-3.7% Failure % Failure 0.01% 0.1% her insertions are Mirena IUDs. Because of the irregular bleeding at the beginning she tells women: “You may Bridging the Gap Communications, Inc. dislike it for a month, but then you’re going to love it for 5 years.” P.O. Box 79299, Atlanta, GA 30357 Phone: 404-875-5001 • Fax: 404-875-5030 is published by Bridging The Gap Communications Sharon A. Rachel, MA, MPH (2011)www.managingcontraception.com P.O. Box 79299, Atlanta, GA 30357 • Phone 404-875-5001 • Fax 404-875-5030 31 www.managingcontraception.com www.managingcontraception.com Choices After Abstinence Cover 9:Layout 1 11/15/10 1:54 PM Page 2

How to Pick a Boyfriend or Girlfriend This imaginative tool outlines three types of partners in terms of their desirability, their potential as a date and their risk to each other. It suggests how a girl or boy could decide if someone is a bad or good possibility as a date or mate. This tool has been tried and loved by college and high school students. If you are in the dating game, consider these issues regarding a potential partner. i t ! Don’t talk to them. Walk away if they… o u t b

a • use drugs like heroin, crystal meth or crack cocaine • use violent words or are physically violent against you or anyone else

t h i n k • are disrespectful of others in their life – like their parents, siblings or teachers

o n ’ t • have children they aren’t supporting

D • are currently having sex with another person • tell you they would never use a condom

! Beware if they… • are much older e t r

b • have lots of former partners they have had sex with e

v • have ever cheated on a partner in the past

e r • don’t like your friends or your parents • don’t think school is that important d e s • have ever gotten into trouble with the police

o u • don’t listen to you Y • make you feel pressured to do sexual things you don’t want to do This is a LARC-friendly publication. It features the This could work if they… k ! Long-Acting Reversible

o r • listen to you

w • respect you Contraceptives, or the • make you feel good about yourself “You Can’t Forget Me” • encourage you o u l d

c • have a life plan that fits your life plan methods, including: • The Mirena® IUD h i s ® T Your questions answered at www.managingcontraception.com • The Implanon implant 2010/11 • The Copper T IUD December 19, 2011