Choosing the right type of contraception can be a delicate balancing act. To establish which is likely to be the most appropriate for you there are a number of things to consider – not least how effective is it in preventing pregnancy but also how straightforward is it to use, how easily reversible are its effects, how safe is it and what you can do if you don’t like the idea of using hormonal contraception?
Dr Hannah Allen, a GP with a special interest in women’s health, says when choosing the right contraception for a patient, ‘I refer to the acronym ICE - Ideas, Concerns and Expectations. In other words, I try to build up a 3D picture of what exactly a woman is hoping to gain from her chosen contraception and unpack any potential problems and health concerns.’ She explains this will involve taking an in-depth history to check your BMI, if you are a smoker, if you suffer with migraines or painful periods, whether you are going through the menopause and/or whether there is a family history of, say, breast cancer, heart disease or blood clots. It will also involve looking at exactly what you expect from your contraception – so, for example, do you want long lasting protection or something that is more easily reversible should be hoping to get pregnant in the near future?
And then which type is most suitable for you personality and lifestyle-wise – maybe you travel abroad often for work or do shift work where your routine differs making it hard to remember to take a pill or patch at a designated time each day or week and/or would prefer something that you don’t have to physically take or worry about for some time such as the coil or an implant?
Understanding what is available, how it works and what modes of delivery are available (eg, pills, patches, coils, implants and so on) should not only help you to take greater control it should also help you, in consultation with your GP, to make the right choice.
What are the best contraception options available for me?
Combined oral contraceptive pill (COC)
This is generally what women are referring to when they say they are ‘on the pill’ – a tablet which contains a combination of oestrogen and progesterone. There are many brands available , such as Microgynon, Rigevidon, Yasmin, Cilique, Eloine, Mercilon, Ovranette, and Levest, with different ones being more suitable than other depending on your needs. The pill should be taken daily at roughly the same time every day.
Pros: It is an effective form of contraception that is easy to take. It can help to reduce heavy or painful periods. There is also evidence to show it may reduce the risk of some cancers such as ovarian, womb and bowel.1 The contraceptive effects are reduced quickly as soon as you stop taking it so it can be a good choice if you are hoping to get pregnant in the near future.
Cons: Side effects can include feeling sick or dizzy, sore breasts and changes to your periods in the first few months of taking it2 . It might seem obvious but you need to remember to take it so if you are someone who has difficulty doing this it might not be the best choice for you. If you vomit or have severe diarrhoea the effectiveness of the COC can be compromised. It isn’t recommended for women with certain medical conditions including some migraines, uncontrolled blood pressure and those with a past history, or family history of, blood clots. If you are over 35 and smoke this might not be the best choice for you because it slightly increases the risk of blood clots.3 Women over 50 are not advised to use the COC or any form of combined hormonal contraception (including the contraceptive patch and vaginal ring). There is a slightly higher risk of breast cancer and cervical cancer for women taking the COC pill.4
The contraceptive patch
Contraceptives such as the Evra patch, contains the same hormones as the COC pill but in patch form. The patch adheres to the skin where it delivers these hormones continuously and it needs to be changed weekly.
Pros: It is easy to use and effective. You don’t have to remember to take a pill every day, your periods tend to become more regular, lighter and less painful and if you are sick or have diarrhoea the patch is still effective because you are absorbing the hormones through your skin and not your digestive tract.
Cons: Side effect can include nausea, headaches, breast tenderness and spotting between periods. Some women report that their skin becomes irritated from wearing the patch and others dislike the fact it can be visible. The patch can also become unstuck and then will obviously not be effective. It carries similar side effects and risks to the COC including an increased risk of blood clots and is not recommended for women over 50.5
Progesterone only pill (POP)
Sometimes referred to as the ‘mini pill’ this contains progesterone only and should be taken every day at roughly the same time. Common brands include Cerazette, Cerelle, Noriday and Norgeston.
Pros: Many women who can’t take the combined oral contraceptive pill are safe to use the POP such as smokers over 35 and those with certain types of migraine. You can also use this type of contraception when breastfeeding. It can help manage heavy and irregular bleeding, such as that experienced during the perimenopause. There are no specific age-related concerns with the POP.
Cons: You need to be more precise when taking the POP than the COC pill. With some makes of POP you have to take them within three hours of the time you took it the day before. With others you have a 12 hour window before it is deemed a missed pill and you are less protected from pregnancy. Your periods can become more irregular. There is also a slightly increased risk of developing ovarian cysts when taking the POP.6 There may be a very small increased risk of breast cancer.7 Some women also report spotting between periods, mood swings, acne, weight gain, acne and changes to their sex drive.8 Some women can also be hyper-sensitive to progesterone, or more likely its synthetic form progestogen, and can experience symptoms similar to those of premenstrual syndrome (PMS) or Premenstrual Dysphoric Disorder (PDD).
The vaginal ring
This is a tiny flexible see-through ring which you insert into your vagina where it releases oestrogen and progesterone to prevent ovulation. It needs to stay in place for three weeks, then you have one week ‘off’ and replace it with a new one. Brands available in the UK are NuvaRing and SyreniRing.
Pros: It is easy to use and effective and you don’t have to worry about taking a tablet every day – but it does still have to be replaced once a month. If you are sick or have diarrhoea it is still effective and your periods are likely to be very regular. It can help improve symptoms of polycystic ovary syndrome (PCOS) and endometriosis. Once you stop using the vaginal ring your fertility should return to normal after a couple of months.9
Cons: It can cause vaginal irritation/soreness. Some women say they can feel it during intercourse which is off-putting. As with other contraceptives it can cause nausea, tender breasts, as well as mood changes, and bloating. It has similar risks to the COC pill including blood clots.
The contraceptive implant
This involves a small implant being placed under the skin (a local anaesthetic is used to numb the area first) which contains progesterone that is slowly released into the body. One injection lasts three years and then needs to be removed and replaced. The only brand available in the UK currently is Nexplanon.
Pros: It is very reliable against unwanted pregnancy and you don’t have to worry about whether you need to take a pill and/or remove and replace a patch. Your periods tend to be very light or non-existent. It is quite easily reversible once removed and your periods should quickly return when it is taken out.
Cons: Periods can become irregular (but nonetheless will be lighter). Some women report side effects such as breast tenderness, abdominal pain, nausea, headaches, weight gain and low mood but these tend to settle down after two or three months. There is a very small risk of infection at the site of the implant.10
The contraceptive injection
This contains a progesterone-like hormone (progestogen) which is released slowly into the body. It needs to be administered by a doctor or practice nurse every eight to 13 weeks, depending on the injection used. The two brands used in the UK are Depo-Provera and Sayana Press.
Pros: It is highly effective, you don’t have to worry about taking pills or applying a patch. Once your body becomes acclimatised to the hormone you often have very light, or possibly no, periods. This is a huge plus if you have heavy and/or painful periods. You can also have the contraceptive injection whilst breastfeeding.
Cons: You periods may become irregular. After stopping the injection it may take up to 12 months for your periods to return to their normal cycle. Some women report side effects such as weight gain, headaches, mood swings and reduced sex drive . Some women are also hypersensitive to the effects of progestogen. Given that you cannot ‘undo’ the injection these side effects can continue for longer than 8-13 weeks. There may a very small increase in your risk of cancers of the breast and womb (cervix). Using the injection for over 12 months has been linked to a reduction in bone density and given that bones can become thinner after menopause this might be another thing to take into consideration with your GP if you are in your late 40s and early 50s.11
The intrauterine contraceptive system (IUS)
This is a small T-shaped plastic device such as the Mirena™ coil w hich releases a tiny amount of hormone called levonorgestrel (a synthetic hormone similar to progesterone) into the body. It is positioned in the cavity of the womb and fitted by a doctor or nurse.
Pros: The IUS can lasts up to 10 years so can be a good option if you know you don’t want to start a family or have completed yours. Only a small amount of the hormone is released into your body so the risk of hormonal side effects tend to be low. It can be an effective way to alleviate heavy periods. The IUS can also be used as the progesterone part of HRT but must be changed after 5 years.
Cons: Some women experience frequent spotting or bleeding for the first three to six months after initially having an IUS fitted. Others report cramping or pelvic pain after first having it fitted and some complain of side effects including headaches, breast tenderness, acne and mood changes. There is also a small chance of getting thrush that keeps coming back.12
IUD (intrauterine device or copper coil)
This is a small plastic T-shaped device, also known as a copper coil, which is inserted by your doctor or healthcare professional into your uterus. It does not use hormones but stops pregnancy by releasing copper into your womb creating a toxic environment for sperm. Its effects can last up to 5-10 years.
Pros: It is a highly effective form of contraception. where you don’t have to worry about remembering to take pills or apply patches. After the IUD is removed your fertility will return to previous levels straight away.
Cons: There’s a tiny risk that the IUD can fail and you can get pregnant. There is also an increased risk of having an ectopic pregnancy in the rare case it does fail. The copper coil can cause pain in the abdomen or lower back for a couple of days after it has been inserted. It can also cause your periods to become heavier and more painful, although this side effect is usually temporary and tends to resolve itself after a few months. There is also a very small risk of infection after getting it fitted or of getting thrush.12
Barrier methods such as condoms (male and female), diaphragm and cap
These work as a ‘barrier’ preventing sperm from entering the womb (uterus).
Pros: There are no serious side effects, although some women can experience mild irritation from the latex or spermicides. Condoms provide protection from sexually transmitted diseases (STDs) and male condoms are easily available and often free at various points.
Cons: They might not be as reliable as other modes of contraception and need to be used carefully and correctly each time you have sex. Male condoms can split or come off and using them can interrupt sexual spontaneity for some. A diaphragm or cap needs to be initially fitted by a doctor or nurse practitioner who will also show you how to use it. It can be inserted up to three hours before sex and then needs to be left in place for at least six hours afterwards. These forms of contraception might not be for you if have a sensitivity to latex or spermicide – which can irritate your vagina and potentially may make you more prone to urinary tract infections (UTIs) such as cystitis. A cap or diaphragm will also need to be replaced annually.
Do you still need contraception if you are going through the perimenopause
When your periods are becoming few and far between during perimenopause it can be tempting to think you can bin your birth control. However, whilst it is less likely, it remains perfectly possible to become pregnant during perimenopause. To understand more read everything you need to know about menopause and contraception.
References
- https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/hormones-and-cancer/does-the-contraceptive-pill-increase-cancer-risk#:~:text=Ovarian%20cancer%3A%20taking%20the%20combined,people%20stop%20taking%20the%20pill.
- https://www.nhs.uk/contraception/methods-of-contraception/combined-pill/side-effects/
- https://www.nhs.uk/contraception/methods-of-contraception/combined-pill/side-effects/#:~:text=Blood%20clots,in%20your%20leg%20or%20lung
- https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/hormones-and-cancer/does-the-contraceptive-pill-increase-cancer-risk#:~:text=Ovarian%20cancer%3A%20taking%20the%20combined,people%20stop%20taking%20the%20pill.
- https://www.nhs.uk/contraception/methods-of-contraception/contraceptive-patch/side-effects-and-risks/#:~:text=Common%20side%20effects%20of%20the%20contraceptive%20patch&text=Some%20people%20have%20headaches%2C%20feel,to%20periods%2C%20such%20as%20headaches.
- https://www.nhs.uk/contraception/methods-of-contraception/progestogen-only-pill/side-effects-and-risks/
- https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/hormones-and-cancer/does-the-contraceptive-pill-increase-cancer-risk#:~:text=Breast%20cancer%3A%20taking%20the%20mini,see%20with%20the%20combined%20pill.
- https://www.nhsinform.scot/healthy-living/contraception/progestogen-only-pill-mini-pill/#:~:text=Some%20people%20may%20experience%20side,%2C%20this%20isn't%20harmful)
- https://www.nhs.uk/contraception/methods-of-contraception/vaginal-ring/what-is-it/
- https://www.nhs.uk/contraception/methods-of-contraception/contraceptive-implant/side-effects-and-risks/
- https://www.nhs.uk/contraception/methods-of-contraception/contraceptive-injection/side-effects-and-risks/
- https://www.nhs.uk/contraception/methods-of-contraception/ius-hormonal-coil/side-effects-and-risks/
- https://www.nhs.uk/contraception/methods-of-contraception/iud-coil/side-effects/
