Happy Birthday to The Pill

Photo by Jenny Lee Silver

The birth control pill turns 50, people rejoice, and the AP writes an overall good article on the Pill's anniversary.

Two things to keep in mind when you read the article. First:

There are Yaz, Yasmin, Seasonale, Seasonique and Lybrel — all with slightly different packaging, formulations and selling points. Lybrel is the first pill designed to eliminate menstrual periods entirely, although gynecologists say any generic can do the same thing if you skip the placebo and take the active pill every day.

For the bazillionth time, no matter which Pill brand you use, you don't have a menstrual period while on the Pill for the duration of use. All that brands like Lybrel or Seasonale do is they either eliminate or shift the frequency of the withdrawal bleeding episode.

Photo by sealibra75

Second:

Female doctors use IUDs twice as frequently as the general population of women and many recommend it to their patients.


"The future of birth control is not pills at all," said Dr. Lisa Perriera, 34, of Case Western Reserve School of Medicine in Cleveland.


"The best birth control is easy to use, highly effective at preventing pregnancy and has few side effects," Perriera said. "The methods that fit those criteria best are IUDs and implants. I think that's where birth control is going."

I couldn't agree more with Dr. Perriera. The Pill is a good method of birth control but other methods, the IUD (ParaGard or Mirena) in particular, are far better. Always keep that in mind when deciding which birth control method to use.

Everybody Loves an Intrauterine Device (IUD)

Your Ob/Gyn is probably using an IUD. So, why aren't you? And for all you physicians out there, don't be an IUD nonplacer [my new favorite word].

From a survey of female employees at a Midwestern University, among heterosexually active, premenopausal nonsterilized respondents (n=4764):

-- Ob/Gyns reported greater history of IUD use than all others (34% vs. 12%).

-- Physicians overall reported greater IUD use than nonphysicians (24% vs. 12%).

-- Clinicians who place IUDs reported more personal IUD use than nonplacers (33% vs. 18%).

-- Among women who intend future pregnancy, 26% of Ob/Gyns reported history of IUD use versus 17% of other physicians and 6% of nonclinician Ph.D.s.

-- 17%, 12% and 4% respectively reported current IUD use and future childbearing intention.

Pregnant While On The Pill

Photo by Lew57

Becoming pregnant, while on the Pill, with twins. Twice! And you thought you had a bad day:

Proud mother Carly O'Brien has beaten odds of 11.3 million to one to give birth to two sets of twins - despite being on the contraceptive pill.

The 22-year-old and her partner John Grant, 28, were amazed when she gave birth to her first set of twins Brandon and Daisy.

Now, two years on, Carly has stunned experts by giving birth to another miracle set of twins - Dylan and Lilly.

...

Carly, from Portsmouth, Hants, had been using the contraceptive pill since she was 17 and never imagined she could get pregnant while using it.

She and John, who installs air conditioning units, had been together for only a year and having children had not crossed their minds.

But when Carly missed a period and started being sick, she may be pregnant.

A pregnancy test confirmed it but it wasn't until her 12 week scan she discovered she was carrying twins.

...

New mum Carly was overjoyed with her two children and, certain she did not want any more, she opted for a stronger contraceptive pill, which had to be taken twice a day.

But, just 18 months later, when Carly missed a period she couldn't believe the supposedly impossible had happened again.

A six-week scan revealed she was again carrying twins - beating odds of more than 11 million to one.

She said: 'I just couldn't believe it and didn't know how it could have happened to me again - especially as I was on a stronger pill.

Now, after the first pregnancy while on the Pill, what could Ms. O'Brien have done to lessen the chance of another contraceptive failure?

Option 1: Double-up.

While the simultaneous use of two methods of birth control, for example the Pill and a male condom, sounds great in theory, it can be problematic. A lot of couples, especially those in long-term, monogamous relationships, are not too keen on using a condom; the risk of noncompliance is quite high.

Option 2: Change Birth Control Methods

This is the one I would've advised. When you've already experienced a failure while taking the Pill, and with twins and no desire to become pregnant again it's time to move on to a more reliable birth control method.

For the Pill, the first year typical-use failure is ~8%.

Compare that with the typical-use failure for the most effective methods:

- Implants (Implanon) 0.05% and IUDs (Mirena, CuT) 0.2% and 0.8%, respectively

- Male sterilization 0.15%

- Depo-Provera 3%




(via)

ACOG ♥ the IUD

via

Ode to the Intrauterine device (IUD) at the annual ACOG meeting in New Orleans:


1. among the most effective contraceptives

2. treatment of heavy menstrual bleeding

3. treatment of endometriosis

4. associated with a 40 percent reduction in the risk of endometrial cancer

5. suitable for both women who've never given birth, as well as for those who have

If you are about to start using a birth control method, or are considering switching methods, I can not urge you strongly enough to give the IUD serious consideration.

After all, the IUD is the bestest, prettiest method of them all.

Embrace the IUD

The findings of a study of knowledge of intrauterine devices among adolescent and young adult women suggest that young women may not be getting sufficient information on all of the contraceptive options available to them, particularly IUDs.

If I were in charge [of the world, mwahahaha], I'd make sure all people of reproductive age are thoroughly conversant with the IUD, one of the best methods of birth control available--safe, effective, and unobtrusive.

Back to the study:

In a cross-sectional survey of 144 young women between the ages of 14 and 24 recruited from an adolescent gynecology clinic, gynecology outpatient clinics, and the community, more than half of the participants had never heard of an intrauterine device (IUD) and 97% had never used one, said Dr. Lisa Johnson of the adolescent medicine division of the Nassau (Bahamas) Department of Public Health.

The 20-minute, 44-item, semistructured interview assessed demographics, sexual history, contraceptive use and attitudes, and IUD knowledge and attitudes, Dr. Johnson said. The mean age of the respondents was 18.8 years. Nearly all (97%) of them were single, 58% were African American, and 39% were white. Approximately 84% of the group had ever been sexually active, with a mean age of 15.8 years at first sexual intercourse and a median of three lifetime partners. Among those who had ever had sex, 76% had ever been pregnant and 67% had ever had a sexually transmitted disease.

According to the survey results, 60% of the young women surveyed had never heard of an IUD, yet a majority of them “agreed” or “strongly agreed” that they would consider a birth control method that resulted in less painful (93%) and lighter (91%) periods and gave them control over when to stop (85%) and start it (80%), Dr. Johnson said. In addition, 61% reported being “willing” or “very willing” to use a birth control method that causes irregular vaginal bleeding if it was 99% effective at preventing pregnancy, she said.

However, only 30% of the respondents said they would consider a birth control method that involved placing a small plastic object in the uterus and only 27% said they would be interested in a device that had to be placed and removed by a health care provider, she noted.

...

Among the young women who liked the idea of an IUD, the most appealing characteristics were that it did not require them to remember to use it every day, that it would not affect their ability to have children in the future, and that it did not need to be remembered with each sex act, Dr. Johnson said.

An IUD For The Boys

Ob.Gyn.News has a quick review of promising male birth control methods. Check out #3, the IVD (Intra Vas Device):

1. Reversible inhibition of sperm under guidance (RISUG). This method of male contraception involves vas deferens injections of styrene maleic anhydride in the solvent dimethyl sulfoxide.

2. Adjudin (also called AF-2364). This is an analogue of an old anticancer drug called lonidamine that is conjugated to follicle-stimulating hormone (FSH).

3. The Intra Vas Device (IVD). This device is composed of a set of two flexible silicon plugs, 1 inch long and either 1.2 mm or 1.4 mm in diameter. The plugs are inserted in the vas deferens, separated by a small space, and they physically block the passage of sperm. After they have been inserted, the patient can neither feel nor palpate the device.

The no-scalpel procedure can be performed by anyone experienced in vasectomy. It is expected to cost about $1,000, which is comparable to a vasectomy. Unlike a vasectomy, however, reversal would theoretically be much simpler and much less expensive—about another $1,000, compared with $5,000-$12,000 for a vasovasostomy.

In May 2006, the Food and Drug Administation (sic) approved human trials with this device, and if all goes according to plan, approval is expected in Europe, Canada, and the United States by 2010.

4. Suppression of spermatogenesis with transdermal testosterone gels plus various progestins.

Long-Term Reversible Birth Control

This should be emblazoned all over the place:

Reproductive-age women have varying contraceptive needs...[T]he method of contraception must be tailored to meet the needs of the individual.

Three long-term birth control methods (.pdf)--ParaGard (copper IUD), Mirena (progestin-releasing IUD), Implanon (contraceptive implant)--three case studies, and three experts. Read the whole thing.

Changes to IUD Prescribing Information

Here's a good summary of the recent changes to the prescribing information (.pdf) for the copper T380A IUD (ParaGard). Some highlights:

- The IUD is the most widely used reversible birth control method in the world.

- Contraceptive efficacy* of the copper IUD is among the highest of all available birth control methods.

* Note this emerging trend in efficacy counseling:

Women report that the most important criterion for choosing a contraceptive is how well it works. However, many women do not fully understand the differences in efficacy among the various methods of contraception or the difference between "typical" and "perfect" use data. Perfect use data should not be used in counseling patients because they are not reflective of real-life practices. [Without any hard data on typical use efficacy, where does that leave abstinence counseling?] Steiner et al have proposed a simplified approach that communicates contraceptive effectiveness better than traditional tables with numeric estimates of pregnancy risk (TABLE 2). This table categorizes sterilization, implants, hormone shots, and IUDs with and without hormones as "more effective"; oral contraceptive pills as 'effective"; and barrier methods, spermicide, and behavioral methods as 'less effective."

(What do you think about this approach? Is it something you'd be comfortable with?)

- Although the acquisition cost of an IUD may be daunting to women whose insurance plans do not provide coverage, the manufacturer does offer a payment plan which can ease the financial burden.

- [T]he copper IUD protects against pregnancy by reducing motility and viability of sperm, inhibiting ova development, and thereby preventing fertilization. This appears to be the primary mechanism of action.

- The most important labeling change was the removal of any reference to a recommended patient profile, which previously had listed parity, a stable and mutually monogamous relationship, and no history of pelvic inflammatory disease (PID) as preferred characteristics for IUD users.

- Nulliparity has never been a contraindication to IUD use.

- The recommendation to avoid IUD use in women with a history of PID has been replaced with the advice not to use an IUD in a woman with active cervicitis, PID, or current behavior suggesting high risk for PID.

- Vaginal infection is not a contraindication to insertion of the copper IUD. Abnormalities in cervical cytology also are not contraindications to IUD insertion or continued use of an IUD; only women who have a high index of suspicion for cervical or endometrial cancer should have their IUD insertion delayed until those diagnoses are ruled out. Women with mild abnormalities on their Papanicolaou test may proceed with IUD insertion prior to colposcopic evaluation.

- The copper IUD reduces a woman’s underlying risk for ectopic pregnancy by 90% and can be used by women with a history of ectopic pregnancy to reduce their risk of recurrence.

- The risk that a pregnancy is ectopic is 8% with copper IUD use; after tubal sterilization, this risk exceeds 20%.

- The copper IUD may be inserted at any time in the menstrual cycle when pregnancy can be reasonably ruled out....Insertion immediately after first-trimester abortion (induced and spontaneous) is both safe and effective.

Quick Ode to the IUD

This cannot be repeated often enough:

Research in the past 20 years...has established that the IUD is an appropriate method for more women (other than [women who could not use hormonal contraceptives, women at low risk of sexually transmitted infection (STI) or monogamous multigravida women]). The IUD is safe, extremely effective and inexpensive. IUDs do not increase the risk of infertility and do not significantly increase risk of developing pelvic inflammatory disease, even in populations with high prevalence of STIs. Upon removal of the IUD, fertility returns almost immediately. The IUD can be provided safely to nulliparous women (women who have never given birth) because its use does not increase the risk of tubal infertility. Regardless of whether a woman has had a child, the IUD is one of the safest methods of contraception, especially if a woman has no STI at the time of insertion. Because of its long-term effectiveness, the cost of the IUD to the health care system is lower than any other method including permanent sterilization.

Contraceptives protect against endometrial cancer

Reuters has an article about the Pill, the IUD, and uterine cancer protection (judging by the title and the leading paragraph, you'd think Reuters is bringing you the latest medical discovery):

NEW YORK (Reuters Health) - Oral contraceptives and intrauterine devices (IUD) appear to provide long-term protection against endometrial cancer, researchers report in the International Journal of Cancer.

This has been reported by several studies, but few have been conducted in Chinese populations, Dr. Xiao Ou Shu of Vanderbilt University, Nashville, Tennessee, and colleagues note.

To investigate further, the team studied 1,204 women from Shanghai with newly diagnosed endometrial cancer and 1,212 healthy women, matched to the cancer patients for various characteristics. The endometrium is the lining of the uterus, or womb.

Overall, 223 of the cancer patients (18.5 percent) and 302 of the controls (24.9 percent) reported using an oral contraceptive.

After accounting for other known risk factors or protective factors for endometrial cancer, the use of oral contraceptives was associated with a 25 percent reduced risk. The risk decreased with long-term use. After 72 months, the cancer risk was reduced by 50 percent.

This protective effect was maintained, even after 25 years or longer after oral contraceptives were discontinued.

IUD use was associated with a 47 percent lower risk of endometrial cancer. The duration of IUD use, and age when it was first and last use did not significantly alter the association.

The researchers suggest that the "the inverse association between oral contraceptives use and endometrial cancer may be due to the progestin component of oral contraceptives," which may help reduce the overgrowth of cell in the endometrium.

The protective effect of IUDs, they add, may be prompted by "inflammatory actions that eliminate abnormal and precancerous endometrial cells; decreased abnormal cell growth -- a known risk factor for endometrial cancer -- and reduce the concentration of estrogen receptors."

N.B. Just in case you missed the fact that this article isn't reporting what Reuters thinks it's reporting: The news isn't that the Pill and the IUD protect against endometrial cancer (that's an established effect), it's that this benefit has now been studied, and observed, in a Chinese population.

Where We Hear From the NY Post And We Are Left Wondering What It "All" Means...Er, "Means"

After noticing several factual inaccuracies about Plan B in a NY Post op-ed, I emailed the columnist:

Ms. Wisse Schachter,

I'm contacting you to alert you to a number of factual mistakes in your op-ed. Briefly:

--Plan B is the "emergency contraception pill[s]", or the "postcoital pill[s]", not the "morning-after pill". [That's an incorrect and misleading term.]

--Plan B is not a pill, it's two pills. Two 0.75 mg levonorgestrel pills, to be exact. [Essential information in view of the new dosage recommendations.]

--Plan B is not basically a double dose of the regular birth-control pill. [Even without defining "regular birth-control pill", Plan B is neither a double dose of the regular progestin-only pill, nor of the EC regimen combination one.]

--Plan B is not associated with "cardiovascular disease, high blood pressure, blood clots, heart attack and strokes." (For that matter, neither are the COC EC regimens.) [In fact, Plan B is the preferred EC method for patients with a history of blood clots or stroke.]

(Full post here.)

Thank you for your time.

ema

Today, Ms. Schachter emails back:

Dear Ema,

Thank you for your message and for taking the time to read and respond to my op-ed.

The side effects listed in my piece are those commonly associated with taking birth control, as I make perfectly clear.

It would have been nice had taken as much time reading the column as you did "rebutting" it.

Regards,
Abby Schachter

First, I appreciate the response.

Second, allow me to address this:

It would have been nice had taken as much time reading the column as you did "rebutting" it.

People, as a rule, when emailing me, assume I'm dense and just say what you mean. Not having to divine intent saves me a lot of time.

I'm not sure, but here's what I think Ms. Schachter's admonition means--"I write a piece focused on the political and social implications of OTC availability of Plan B, and you 1) don't address those issues at all, and/or 2) refute them [not] by pointing out, and correcting, the factual mistakes about Plan B." Correct and incorrect at the same time.

Correct, because all I did was address the factual mistakes about Plan B--what it is, it's side effects, etc. My position (and concern) is that, unless we know the basics about a drug, we cannot have an informed discussion about the politics surrounding it.

Incorrect, because, by pointing out the mistakes about Plan B, I was not rebutting anything; I wasn't presenting any opposing evidence to Ms. Schachter's opinions. The facts about Plan B, like its progestin-only content, are not up for debate. It's not a "she said", "she said" situation. We don't each get a few minutes to make our case. Plan B's composition, or side effects for that matter, are a given, independent of anyone's argument/counterargument [you know, the "science" part].

Last, but not least, we have this:

The side effects listed in my piece are those commonly associated with taking birth control, as I make perfectly clear.

Here's the thing [yes, I know, I'm watching way too much Monk]: 1) the side effects listed in the piece are not those commonly associated with taking birth control, and 2) there's nothing even remotely clear [not to mention correct] about Plan B's side effects in the piece.

There are seven groups of birth control, and over eighty individual methods:

1. Hormonal Group

-Combination Pill

-Progestin-only Pill

-Skin Patch

-Vaginal Ring

-Implants

-Shots

-[Hormone-releasing IUDs]

2. Nonsteroidal Pill Group

-Centchroman

3. Intrauterine Device Group

-Older IUDs

-Frame IUDs

-Frameless IUDs

-[Hormone-releasing IUDs]

4. Barrier and Spermicide Group

-Condom (male, female, and unisex)

-Diaphragm

-Cervical Cap

-Ovès Cap

-FemCap

-Lea contraceptive

[Good pics here.]

-Sponges

-Spermicides

5. Natural Family Planning Group

-Continuous Abstinence

-Outercourse

-Sexual techniques

-Breastfeeding

-Fertility Awareness

6. Sterilization Group

-Male

-Female

7. Emergency Contraception Group

-Combination Pill

-Progestin-only Pill

-Antiprogesterone Pill

-Progesterone production blocker Pill

-IUD

These are the side effects listed in the op-ed:

...mild, such as dizziness, weight gain and irregular periods. ... more serious, if rare - cardiovascular disease, high blood pressure, blood clots, heart attack and strokes.

Ms. Schachter says these are the side effects (emphasis mine) commonly associated with taking birth control. Since we're talking about common side effects, everything after rare (cardiovascular dz, HTN, blood clots, heart attack and strokes) is out.

So we're left with dizziness, weight gain and irregular periods. According to Ms. Schachter, these are the side effects commonly associated with taking birth control. Really? When's the last time your partner's condom use caused you to gain weight?

Okay, I'm being facetious, but you get the point. There's no such thing as side effects ... commonly associated with taking birth control. That's because a method's side effects depend on group, mode of action, dosage, route of administration, risk factors, etc..

Even if Ms. Schachter was only referring to the Hormonal Group when listing the side effects, it's still essential to be accurate.

Cardiovascular disease, high blood pressure, blood clots, heart attack and strokes are not common side effects of methods in the hormonal birth control group. They are rare effects of some of the methods--the combination (estrogen + progestin) ones--in this group. [To give you an idea ...even deaths due to rare events, such as accidents or homicides, are much more common than deaths due to OC-related adverse events.*]

Moreover, the Hormonal Group and the EC Group are not one and the same. The side effects associated with combination methods in the Hormonal Group differ from those associated with combination methods in the EC Group. Cardiovascular disease, high blood pressure, blood clots, heart attack and strokes are not side effects--rare or otherwise--associated with combination (estrogen + progestin) EC regimens. [From my previous post: No deaths or serious complications have been causally linked to emergency contraception.]

Last, but not least, Plan B is a PROGESTIN-ONLY method. Its side effects differ from the combination (estrogen + progestin) methods in the EC Group.

Which brings us to Ms. Schachter's assertion that she made it perfectly clear in her piece that the side effects she lists are commonly associated with (?hormonal/?estrogen-progestin) birth control, in general, not Plan B. I disagree, and here's why.

In a piece

...titled 'PLAN B': What Science Can't Tell Us...

...containing the statement But it plainly is all about Plan B...

...focused on issues surrounding the approval of OTC sales of Plan B...

...stating that OTC approval of Plan B is troubling because women could get it without the benefit of a doctor's warning about side effects...

Well, approval raises a host of troubling questions. For one: Since it's only a double dose of regular birth control, women over 18 (or girls with fake IDs) could get "the pill" without a prescription - or a doctor's warnings about side effects.

...personalizing the issue of lack of physician counseling about side effects, if Plan B becomes available OTC, by quoting an Ob/Gyn's concerns about losing the opportunity to present medical issues associated with OTC sales of Plan B...

Medical professionals have doubts. Dr. Vivian Roston, an OB-GYN at St. Luke's Roosevelt Hospital, worries that over-the-counter access to emergency contraception [that would be Plan B] means she won't have the chance to educate her patients. "I wouldn't want someone not to have access [to emergency contraception]," she told me. "But then again, you lose the opportunity to present all the medical issues associated with taking a high-dose hormonal drug" [again, Plan B] if a woman doesn't have to see a doctor to get it.

(emphasis mine)

...where the above paragraph--about Dr. Roston's worries that OTC sales of Plan B would rob her of the opportunity to discuss with women medical issues associated with taking Plan B--is immediately followed by an enumeration of side effects...

Of course, some of the risks are mild, such as dizziness, weight gain and irregular periods. But others are more serious, if rare - cardiovascular disease, high blood pressure, blood clots, heart attack and strokes.

it is not at all perfectly clear that the listed side effects are not those associated with Plan B, but rather those associated with some mythical "birth control".

Bottom line: This is not about Ms. Schachter's opinions on OTC sales of Plan B, or my reading comprehension and/or debating prowess. It's about the duty of a publication like the NY Post to present factually accurate medical information to its readers. Or not; in which case the NY Post should have no objection to publishing my article entitled "Plan B Causes Cooties."


*Dialogues In Contraception. Winter 2002;7(7):4

Skip Your Period and Period Control Options

Good AP article on the available options for period control, as well as some coming attractions.

Among the existing methods:

- Seasonale: 30 μg of estrogen (ethinyl estradiol, or EE)/150 μg of progestin (levonorgestrel), taken continuously for 84 days, followed by 1 week off.

- Ortho Evra patch: 0.75 mg estrogen (EE)/ 6.00 mg progestin (norelgestromin) [20 μg estrogen/150 μg progestin per day], one patch per week for 8 or 12 weeks in a row, followed by 1 week off.

- NuvaRing vaginal ring: 2.7 mg estrogen (EE)/11.7 mg progestin (etonogestrel) [15 μg estrogen/120 μg progestin per day], one ring in place for 3 weeks at a time, for 6 or 12 weeks total in a row, followed by 1 week off. [Alternatively, one ring can be left in place for 4 weeks at a time.]

- Depo-Provera [and Depo-subQ provera 104] shot: 150 mg progestin (medroxyprogesterone acetate) [104 mg progestin], one injection four times a year.

One more existing brand worth mentioning is Loestrin 24 Fe. The innovation here is the shortened placebo interval--one estrogen/progestin pill taken for 24 days, followed by one iron-containing placebo pill taken for 4 days. [Of course, if you're already taking the Pill, and you want a shorter placebo interval, you can use your existing brand to do that. Just take 4 placebo pills, instead of the usual 7, followed by a new pack.]

And some newer developments:

- Seasonique: 30 μg of estrogen [EE]/150 μg of progestin [levonorgestrel]), and 10 μg EE, one estrogen/progestin pill taken continuously for 84 days, followed by one estrogen-only pill for 7 days; no placebo interval.

- Lybrel: 20 μg ethinyl estradiol/90 μg levonorgestrel, one estrogen/progestin pill taken daily with no placebo intervals.

- Implanon*: 68 mg progestin (etonogestrel) [~40 μg progestin per day], one-rod implant lasting up to 3 years.

*Just like so many other methods before it (Mirena, Depo-Provera), Implanon has been available for over a decade outside the U.S.. This pretty much insures Implanon's status as a "cutting edge" method over here.

Implants and Intrauterine Devices (IUDs)

Two very good questions: is Norplant still available, and what about IUDs?

Implants

What is an implant?

An implant is one of the six types of hormonal methods of birth control. Implants come in the form of one/several small plastic rods, or a capsule which are inserted under the skin (of the arm, usually).

Each rod has a small amount of only one hormone, a progestin.

The number of rods, and the amount and type of progestin depend on which brand of implant you use. The rods are inserted and removed by medical personnel. Used since 1983, implants are widely available worldwide, except in the United States. Unfortunately, in 2002 Norplant, the only implant available in the U.S., was withdrawn from the market. (Yet, another entire class of birth control methods unavailable to American women. These would be the same women that most of these methods are tested on to begin with, a "minor" detail of course. But I digress.)

The five implant brands are:

1. Norplant: this is the original 6-rod implant; it can be left in place for up to five years

2. Jadelle (Norplant II): this is a 2-rod implant; it can be left in place for up to five years

3. Implanon: this is a single-rod implant; it can be left in placed for up to three years

4. Nestorone: one type consists of a single rod that lasts up to two years, while another type is a small capsule that lasts for six months. The six-month system is available in Brazil under the brand name Elcometrine. It is used to treat endometriosis.

5. Uniplant: this is a single-rod, one year implant (not available commercially).

In general, if you've been using Norplant and you'd like to continue using an implant, the best alternative is one of the newer brands, like Implanon or Jadelle. Of course, just because implants aren't available here, doesn't mean you have to go without. You have two options. If you're planning to travel outside the country, for example to Europe (or anywhere else for that matter), you can have the implant inserted there. Or, you can ask your Ob/Gyn to order the implant directly from the manufacturer. Just make sure he/she is familiar with the method, and is willing to accommodate your needs (there's quite a bit of paperwork involved).

Moving on to intrauterine devices (IUDs), what is an IUD? It is a small device that is inserted inside the uterus, and it's classified as a separate class of birth control. However, there is some crossover: hormone-releasing IUDs can be grouped together with the hormonal methods of birth control. Many types and brands of IUDs are available. Er, that is if you happen to live outside the U.S. In the States, only two brands are available: ParaGard and Mirena. Let's review the main groups of IUDs, so you may better understand your options.

IUDs are non-medicated or medicated (copper- and hormone-releasing), and either framed or frameless.

The non-medicated (or inert) IUDs have an inert plastic frame. Most of the older brands are inert: Graefenberg, Ota rings (these were used in the 1920s), Lippes Loop, Dalkon Shield, Saf-T-Coil, Spring coil, Margulies coil, Majzlin spring, Szontagh, Dana-Super, etc. As a rule, inert IUDs can be left in place for decades.

The framed copper-releasing IUD consists of an inert plastic frame (usually in the shape of a "T", "Y", or a "7") to which copper wire is added. Some brands also have silver wire (the ones with "Ag" in their name). Many types of copper-releasing IUDs are available (by 1974 there were over 20 types available; many more have been developed since). These IUDs may be left in place for up to 10 years. Some of the older types (first generation) are: Copper 7 (Cu-7/Gravigard), TCu-200, Copper T, ML Cu-250, Tatum-T, etc. The major second-generation IUDs are the TCu-380A (ParaGard) and the newer, improved version TCu-380S (Gyne T Slimline), Nova T, and Multiload-375 (MLCu-375) standard and SL. Other brands include the Nova-T380, DanaCu, Superlux, and Ombrelle250. The newest types of copper-releasing IUDs are: Cu-Safe 300 (Flexi-T 300), Fincoid-350, and Sof-T.

In the U.S., only one type of copper-releasing IUD is available, an older brand, ParaGard.

The copper-releasing frameless IUD, as the name implies, doesn't have the rigid, or semiflexible plastic frame seen in the framed type. The frameless IUDs currently in use are GyneFix (scroll down for the picture) and GyneFix mini, which consist of six (four) small copper sleeves threaded on a suture string. The upper end of the thread has a knot which serves as an anchor. (The knot is anchored into the top area of the muscular wall of the uterus; this secures the device in place.) The frameless IUD may be left in place for up to 5 years.

Finally, the hormone-releasing IUD is one that releases a hormone (a progestin). The type available in the U.S. is an older, framed brand Mirena (it's been available in Europe for over a decade). Mirena may be left in place for up to five years. Two newer types of hormone-releasing IUDs soon to be available in Europe are the framed Femilis T (ten years life span), and the frameless FibroPlant (three years life span).

Obviously, each type and brand of implant and IUD has its advantages and disadvantages. In order to find the one that's best suited to your unique needs, make sure you go over the details of each group with your Ob/Gyn.