22 Dec Which contraceptive should I choose?
Ask the Lady Doctor – Which contraceptive should I choose? (Part 5)
This is the final instalment of our series about contraceptive choices. So far we’ve covered rhythm and barrier methods, IUDs and oral contraceptives. This article will look at injectables, implants and surgical options to prevent pregnancy.
Injectable medroxyprogesterone (Depo-Provera)
This method of birth control quickly gained popularity when it became available in Canada in 1997. Depo-provera is a progestin that is injected intramuscularly by your family doctor once every 2-3 months. It functions much the same as the pill – inhibiting ovulation, altering cervical mucus and creating an inhospitable endometrial lining. It is 100% effective with no reported failure rates.
Initially, the main drawback to this form of contraception was thought to be that many women experienced menstrual disturbances ranging from frequent, irregular periods to heavy bleeding to no bleeding at all. However, since the approval of this contraceptive in 1997, there has been an opportunity to study long-term side effects. It was soon realized that there were other more sinister problems associated with using the “depo” injection, namely, significant weight gain and temporary loss of bone density.
Another concern with injectable progestins is that there is a delay in the return of fertility following cessation of the medication. On average, it takes 9 months, (and possibly as long as 18 months) before conception will occur. This may be a concern for some women. However, not having to remember to take a pill every day and the reliability of this method make it very attractive for some people.
In 2020, Depo-Provera is a minor player as a contraceptive choice for Canadian women. It is estimated that only about 2-3% of women elect to use it. Physicians have been steering away from recommending it due to its side effect profile.
The progesterone implant – Nexplanon
As of September 2020, Canada has approved the progesterone implant: a small, soft plastic rod about the size of a matchstick. The implant contains a progestin and it is inserted underneath the skin of a woman’s upper arm in a simple office procedure.
The implant releases a relatively constant amount of medicine for a period of 3 years. This method prevents conception very effectively. Ovulation is suppressed in some women; however, the primary mode of action is to cause thick, scanty cervical mucus – preventing sperm migration. It also suppresses the development of the endometrial lining of the uterus. As with the hormonal IUD and the Depo-Provera shot, the main side effects associated with use involve irregular bleeding, spotting between periods and total cessation of menses. Often, these irregularities disappear after a few months.
Post-coital contraception (The “morning after pill”)
The “morning after pill” (MAP) is basically just a regular birth control pill that is doubled up. It should be taken within 72 hours of intercourse but preferably within 24 hours. Two pills are taken (often with an anti-nausea medication); 12 hours later two more pills are taken. This high dose of steroids is generally very effective at preventing implantation of the embryo – it is virtually the same as taking oral contraceptives on a regular basis (i.e. 1-2% failure).
Mifepristone (RU-486) “The Abortion Pill”
This pill has been available under the trade name Mifegymiso to Canadians since 2017. Its use is highly controversial. Basically, it disrupts normal progesterone activity to induce a miscarriage. It may be used up to the 7 weeks of pregnancy.
Mifegymiso is actually two different pills: A single dose of mifepristone is given initially to block development. A couple of days later, a second pill of misoprostol will cause cramping and bleeding within 72 hours. A follow-up appointment with your family doctor is recommended within a couple of weeks of miscarriage.
Side effects of the RU 486 include:
- Cramps
- Pelvic pain
- Vaginal burning, itching, or discharge.
- Headaches.
- Tiredness
- Difficulty falling asleep or staying asleep
- Anxiety
- Back or leg pain
This pill is considered to be extremely safe and has been used by women all over the world since 1988.
Available only with a doctor’s prescription, Mifegymiso was used at least 4000 times by Canadian women in 2018.
Surgical Choices
Of course, many women who have completed their families elect for surgical sterilization also known as a tubal ligation. This is major surgery requiring a general anaesthetic. The gynecologist will make a couple of small incisions in the abdomen. The fallopian tubes are located and cut. The cut ends are usually tied off (or sometimes cauterized), hence the lay term of “having one’s tubes tied”.
My usual advice to couples considering sterilization is two-fold. Number one: consider it permanent. Even though there are reversal procedures, they are not guaranteed. The longer tubes are “tied off” the less likely a surgeon will be able to reverse the operation and restore fertility. This is also true for reversing vasectomies (the male equivalent procedure).
The second caveat is to consider vasectomy over tubal ligation. A vasectomy is a minor procedure that can be done in 15 minutes under a local anaesthetic in an urologist’s office. It is much less trauma to the body with few complications (and none of the major problems that can be associated with major surgery!) This is practical advice that all couples need to consider. (Of course the major challenge here is to convince your male partner that this is a “minor procedure”. Men tend to have difficulty with the words “scalpel” and “scrotum” in the same sentence!)
This series of articles has attempted to give the reader a good overview of available contraceptive choices. The information is by no means complete and I urge you to have your questions answered by your family doctor.
Family planning is important. I strongly believe that women should have control over when and if they choose to have children. However, I also believe that this “choice” is best made PRIOR to conception rather than afterward. There are many effective methods of birth control. Select one that is right for you and don’t tolerate unpleasant side effects when there are so many alternatives to choose from!
Recommended Online resources:
Options for Sexual Health – Birth Control
Teen Health Source – the Abortion Pill
Medical Text Reference: Beck, William. Obstetrics and Gynecology, 4th edition. Williams & Wilkins. 1997.
More :
Part-1 : Natural Family Planning
Part-2 : Barrier Methods of Contraception
Part-3 : Contraceptive – IUD
Part-4 : Oral Contraceptive Pill
© Ask The Lady Doctor 2020 Dr Shannon Lee Dutchyn, MD, CCFP, FCFP