Contraception

I have a question from a female friend; she and her boyfriend are in a long term relationship. They're both serious about it and there's not really any risk of STD (since it's a single partner situation) so she was looking for an alternative contraceptive that would allow her and her boyfriend to have sex without a condom. What would your recommendation be, how reliable are the various options, and how safe are they?

As a biologist I know a fair amount, but I'm sure you have more specific knowledge of this than I do, so I thought I'd ask the expert.

Before they decide to go on an alternative form of birth control they should both get tested to find out if they are both disease free and keep in mind that 1. Sometimes certain STIs won't show up on a test for 6 months after it has been contracted and 2. There are some STIs that may not have tests like HPV in men and some STIs that aren't automatically tested for like herpes. When they go in to get tested they need to specifically tell the doctor/nurse that they want to be tested for HIV and Herpes as well.

If they are both clean then they can start thinking about what kind of birth control she wants to be on. There are several on the market, some are more effective than others and some have more side effects than others. Any hormonal forms of birth control are going to have more side effects than non-hormonal forms, but they will also be more effective. If a woman is over 35 or smokes she should not use hormonal forms of birth control as they increase the risk of blood clots and stroke.

First, the hormonal forms:
The most used form of birth control in the US is The Pill. There are many many different brands of pills out there with different hormone dosages. Finding the right one can be difficult, but worth it to find one that works well with a woman's body chemistry. The goal is to find the pill with the least amount of side effects that actually makes life easier, not more difficult. A woman's doctor or nurse should work with her to find the right dosage. Some possible side effects include: nausea, weight gain, fatigue, moodyness, loss of sexual desire, depression. The Pill is about 99% effective when used correctly. If you cannot remember to take your pills at the same time every day then they will not be anywhere near as effective. They are also less effective if you take St John's Wart or are on antibiotics.

If you cannot remember to take your pills every day at the same time there are a few other options. The NuvaRing is a small plastic ring that a woman inserts into her vagina that emits a low dosage of hormones. The ring is kept in place for 3 weeks and then on the fourth week the woman must take it out to allow for her period. After that week is over she puts in a new ring. The NuvaRing is just as effective as The Pill if used correctly and also has the same side effects. This option should not be used if a woman is at all squeamish about touching her genitals or feeling around inside of her vagina. It may also be more expensive than The Pill and is not covered under a lot of insurance plans.

Another option is The Patch, Ortho Evra. This is a patch that is placed on the body for a week at a time for 3 weeks, with a week off for your period. The patch sends hormones through your skin and into your blood system. The patch has more estrogen in it than The Pill and may cause more side effects because of that. It is as effective as The Pill if used correctly. There is risk of The Patch falling off if a woman leads an active (read: sweaty) lifestyle and if this is not noticed right away it can increase risk of pregnancy. The Patch can also cause irritation to the skin where it is applied.

Another option is Depo Provera. This is a shot that the woman gets once every three months. If a woman has a difficult time remembering to do the above three options then depo may be a good option. However, depo is in your bloodstream for 3 months, which means that you are stuck with any bad side effects that you may have for three whole months. This can be unbearable for some women. Depo is, however, very effective since there is very little risk of human error. It is about 99% effective.

There are two types of IUD (Intrauterine Device), hormonal and non-hormonal. The hormonal type is in the shape of a small T, is made out of plastic, and releases progesterone into the body, which thickens the cervical mucus making it difficult for sperm to reach the egg and also by changing the lining of the uterus so that a fertilized egg cannot implant. The device is inserted by a doctor and can be used up to a year. It is 98% effective, but should only be used by women in longterm monogamous relationships as the IUD can cause severe complications if the woman contracts an STI. This caution should also be noted for the non-hormonal IUD as well as the IUS, which follows.

The Intrauterine System (IUS) is very similar to an IUD but the big difference is that it releases a small amount of the hormone levonorgestrel into the body that thickens the cervical mucus which makes it difficult for the sperm to reach the egg. It has to be placed into the uterus by a doctor and stays in for up to 5 years. The IUS is 99% effective.

Non-hormonal options:
The diaphragm, like the condom, is a barrier method, which means that it blocks the sperm. Unlike a condom though, the diaphragm is put into the vagina, covering the cervix so sperm can get into the vagina, but not into the uterus or fallopian tubes. Diaphragms need to be fitted by a doctor and they are a lot less effective than hormonal methods. The chance for human error is also greater. Diaphragms should be used with a spermicide, which makes them more effective, but spermicides can also be harmful to the delicate tissues of a woman's vagina. Diaphragms with spermicide are about 86-94% effective. If a woman chooses this method she should not feel squeamish about touching her genitals or reaching inside of her vagina.

The cervical cap is a lot like the diaphragm, but instead of simply covering the cervix, it is fitted to snuggly cap the end of the cervix. The cervical cap should also be used with a spermicide and is about 84-91% effective, but that effectiveness goes down if the woman has previously given birth.

The sponge is a soft disk shaped device made out of polyurethane foam and contains the spermicide, nonoxynol-9. As stated above, spermicide can cause harm to the tissues inside of the vagina. It doesn't effect all women, but if a woman has had problems in the past she should not use this method or any of the non-hormonal methods mentioned above. The sponge is a bit easier to remove than the cervical cap, diaphragm, and NuvaRing because it does have a small loop attached for ease of pulling it out. But if a woman is at all squeamish about touching her genitals, she should still not use this method. The sponge is about 84-91% effective depending on correct usage, but that effectiveness goes down if the woman has previously given birth.

The IUD, or intrauterine device, is a small t-shaped copper device that is placed into the uterus by a doctor and left for up to 12 years. This device is very effective and there are a few theories as to why exactly. Some include the device's material and some include the shape of it. But basically what any woman needs to know is that it prevents pregnancy by making it practically impossible for a fertilized egg to implant itself in the lining of the uterus. It is about 99% effective. This device should only be used by women in longterm monogamous relationships for the same reason as described above for the hormonal IUD and the IUS.

The last 2 non-hormonal methods are the Rhythm Method and the Withdrawal Method and I really advise against both unless you are a couple who doesn't particularly want to get pregnant, but wouldn't mind it if it happened. These are methods that should never be used by young people as they do not have enough self control. The rhythm method is when a couple only has sex when a woman is least likely to get pregnant. The withdrawal method is when the man withdraws his penis from the woman's vagina right before he ejaculates so that he does not get any sperm into her vagina. Neither of these methods are very effective, but can increase the effectiveness of any of the methods listed above.