Thursday, July 29, 2004

More Birth Control Methods

Never one to pass up a good discussion on birth control, let me see if I can add some information. Before we start, please keep in mind that this is going to be an extremely superficial review. (Just to give you an idea, the page count for my book is ~263 pages. All the methods mentioned in Vanessa's post are covered in detail, over more than 100 pages. So, again, what follows is very brief, and selective.)

First, read the article that inspired the initial post. Now, let's gently correct and add to it.

The U.S. Food and Drug Administration approved the first oral contraceptive pill in 1960...

Actually, the first birth control pill was approved in 1957. That is, it was approved for period control (to manage period-related problems). Only later, in 1960, was it also approved for birth control. (Just in case you were wondering how long this period control thing has been going on.)

"There have been no changes in the pill until the last few years," said Dr. Ted Peskin, professor of obstetrics and gynecology at the UMass Medical School in Worcester. "Just (recently) have all these adaptations to take birth control hormones (come out)."

Um, only if you've been living in the U.S. Most "adaptations" have been around in Europe for over a decade. As a rule, even if a birth control method is developed here and tested on American women, assume it will be available first in Europe, and about 5 to 10 years later here. (Can you tell I have a bit of a bee in my bonnet about this?)

Three-month pill -- This recently FDA-approved oral contraceptive directs women to take the pill daily for three months, rather than three weeks, allowing only four menstrual periods a year. Common brand name: Seasonale.

Vanessa wants to know if she should be excited or freaked out about Seasonale? Very good question, answered in detail in my book. However, since the release date is October (may I just say, "brilliant" marketing to schedule release around the time of a crucial Presidential election) we can't wait that long.

Briefly, when you use the Pill, on the regular birth control schedule (3 weeks on/1 week off), you no longer have a menstrual period. This is normal, and it's the way the Pill works. Again, if you use the Pill for, say, 5 years, you don't have a menstrual period for 5 years. So, when you use Seasonale, your menstrual periods are not affected at all, since you don't actually have any.

What you do have when you use the Pill, on the regular schedule, is a monthly withdrawal bleeding episode. (For clarity, I'll refer to withdrawal bleeding as the fake period.) Your menstrual period and your fake period have nothing to do with each other; they're not one and the same thing. The fake period is an artificial event, caused by manipulating the amount of hormones in the pill. The only reason you get a monthly fake period is because you take a specific dosage. Change the dosage and the monthly fake period is no more.

Moreover, there is no medical or biological reason to have a monthly fake period when you're on the Pill. The reasons the monthly fake period was built in the Pill are "designer" ones: Puritanical politicians, doctors who didn't wash their hands, Catholic Popes, and dead rabbits. (I'm not being flippant; these are actual, historical reasons.) So, when you take Seasonale all you're doing is changing the frequency of the fake period, from monthly to trimonthly. Of course, just knowing about the real and the fake period isn't enough to fully answer our initial question about Seasonale. There are other factors you need to consider before you can make an informed decision, but we have to move on.

Three-month shot -- A progesterone injection, administered by a doctor, that lasts for three months to prevent pregnancy. Common brand name: Depo Provera.


Peskin said side effects of the three-month shot could include a slight weight gain of 5 to 10 pounds and irregular bleeding for the first three to six months, followed by no periods after a year.

Only one randomized clinical trial has studied the effect of Depo-Provera on weight. It found no evidence that Depo-Provera increases appetite or weight. On the other hand, several observational studies that looked at this effect have reported conflicting results: some reported weight gain of up to 16.5 lbs after 6 years of use; others reported no weight change.

Regarding the irregular bleeding, about 35% of users experience irregular bleeding, and 27% experience prolonged bleeding during the first 3 to 6 months of use. After one year of use, about 50% of women become amenorrheic (stop bleeding altogether).

The Patch -- A weekly one-and-three-quarter-inch patch that releases hormones through the skin directly into the bloodstream to prevent pregnancy. Women put on a new patch once a week for three weeks, allowing for a menstrual period during the fourth week each month. Common brand name: Ortho Evra.

Ortho Evra is a good method to use if you don't want to remember to take a pill every day. And just because it's a patch, doesn't mean you have a real menstrual period. Just like with the Pill, you only have fake periods when you use the patch. (This is one of the newer methods; it's only been available for ~2 years).

The Ring -- A flexible two-inch diameter ring inserted into the vagina to release hormones for three weeks to prevent pregnancy, allowing for a menstrual period during the fourth week each month. Common brand name: Nuva Ring.


"The ring in my practice is very popular because I use it a lot," Power [a Leominster gynecologist] said. "Women can be squeamish at first, but often women who get it, like it."

Two possible reason to be squeamish about NuvaRing: once you insert it, you can still feel it; either you or your partner can feel it during sexual intercourse. For the first scenario, take it out and re-inserted right away. Remember, the ring is not a barrier method, so it doesn't need to fit over the cervix. Second scenario, take it out (and leave it out) while you're making love, and re-inserted once you're done. Very Important: don't leave it out for more than 3 hours! (This ring is also one of the newer methods; it's been available for ~2 years.)

Intrauterine Device -- A small device inserted by a doctor into the uterus to release hormones that prevent pregnancy, which can last five years or more. Common brand name: Mirena.


Peskin said an intrauterine device, called IUD, is also a safe, effective form of birth control.

"It got a bad (reputation) in the U.S. because of the previous infection rate, but that's based on old information," Peskin said.



I could not concur more with Dr. Peskin: the IUD is one of the best methods of birth control. Despite the fact that sterilization ("having the tubes tied") is the most common method of birth control used by American women, the IUD offers you better pregnancy protection: 0.4 vs. 0.1 first year failure rate. And this only scratches the surface. For years, the Europeans have been using the "next generation" IUDs, GyneFix and GyneFix mini (both frameless IUDs). Bottom line: maybe the IUD is the best method for you, or maybe not. What is unquestionably best for you: to be aware of all the available birth control options, so that you, in consultation with your physician, can make not only an informed decisions, but one that best fits your unique needs.

Finally, one feministing commenter mentioned Pill/patch/ring use and side effects, in particular: diminished sex drive, mood swings, and increased growth of body hair (hirsutism).

Both natural (body-made) and synthetic (man-made) hormones can cause side effects. For example, too much natural estrogen increases your risk of uterine cancer; too much synthetic estrogen increases your risk of blood clot complications. As a rule, most of the side effects of hormonal birth control are "minor" (BTS, breast tenderness, etc.); the life-threatening ones are rare. (However, if you decide to use a hormonal method, you should be aware of all the risks--minor, as well as major ones.) I don't have time to go over all the risks now, but allow me to clarify something about the three aforementioned risks: diminished sex drive, mood swings, and hirsutism.

Female sex drive (libido) is a complex issue. In other words, in men, low testosterone levels = low sex drive. In women, just measuring the testosterone level is a problem. (Women have much lower levels vs. men, and most tests are not sensitive enough to accurately detect them.) Moreover, in women there's no such thing as a "set" relationship between the testosterone level and libido. That's because, in women, sex drive is determined by a number of factors--past sexual experiences, estrogen levels, etc. (In other words, even if you give a woman with low testosterone levels, and a low sex drive, supplemental testosterone, the physiological response can be present--more blood rushes to the vagina--but her sex drive isn't changed--she reports no improvement in sex drive.) But I digress; back to the Pill and its effect on sex drive. Some ongoing Pill users report an increase in sexual thoughts. Some women who discontinued Pill use report reduced sexual thoughts. The [limited] studies available suggest that Depo-Provera (and Lunelle, a combination shot not available in the U.S.) rarely cause loss of sex drive (or depression, for that matter). Bottom line: some women do perceive/experience changes in sex drive and mood when using hormonal birth control; however, a direct relationship between these changes and the hormonal birth control method is not always evident.

Hirsutism, or, in a woman, an increase hair growth in a male pattern, is caused by an excess of "male" sex hormones, like testosterone. (Mind you, both men and women produce testosterone; however, because men produce much higher amounts, testosterone is referred to as a "male" hormone.) So, in order to treat hirsutism you want to lower the testosterone level. Enter the Pill, one of the methods used to actually decrease hirsutism. Again, the Pill decreases hirsutism, it doesn't increase it. The way it does that: by reducing the amount of free testosterone (the free fraction is active; the bound one isn't). Incidentally, this is the same mechanism by which the Pill decreases and improves acne.

OK, enough for today. I'll try to post something about male birth control soon.

I just realized I left out one "designer" reason for creating a fake period, one that has to do with doctor's shortcomings. (A bit biased in favor of doctors, aren't we?--ed Yes, but only a bit.) I've amended the original text.

A commenter points out that Seasonale was only approved in 2003. Correct. However, Seasonale is not so much a "new" method, as it is a new brand name (over 10 other brands have the exact same formulation), and pack/label. In Europe, Pill packs already carry these labels; even in the U.S. this regimen has been used for decades. Granted, Seasonale's pack looks much nicer than pill strips with the placebo pills cut out, and held together with a rubber band; still it's more of a form novelty vs. a function one. (Contrast this to the patch. Until Ortho Evra came out there was no other brand/method that delivered birth control through the skin.) In any case, I must admit that when I wrote the post it hadn't even occurred to me that what I just mentioned here wasn't common knowledge. Perhaps we in the medical profession haven't done such a good job of educating women about this topic? (I'd rather like to believe I'm wrong about this.)

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At 2:16 PM, Anonymous Anonymous said...

Seasonale was released last year, October *2003*

At 7:20 PM, Blogger Amanda Marcotte said...

I definitely had to shave less when I was on the pill, I can attest to that.

At 3:43 PM, Blogger Patti said...

I have to say having tried almost every hormonal birth control method the best was Lunelle. It was the same as the pill, but a monthly injection. I hated Depo, never recommend it - weight gain, sporadic or lengthy bleeding, trying to get women to understand the 2wk window between shots. NuvaRing wasn't bad either, it will come out during sex - I did not feel it other wise. OrthoEvra patch was horrible - it would start to come off before the end of the week and I had welts from the adhesive.

Lunelle was produced by Pharmacia in 2 forms. As a pre-filled syringe and in vials. Only the pre-filled syringes were possibly faulty but they recalled all of Lunelle. Around the same time (OCT 2003) Pharmacia was aquired by Pfizer. Pfizer discontinued Lunelle. I called both companies (at the time) multiple times for information on Lunelle.
The ONLY form of birth control that Pfizer manufactures is Depo-Provera (aquired from Pharmacia/UpJohn) and continues to manufacture it due to agreements with the WHO. Guess what Pfizer did develop (not acquire)-Viagra.
You tell me their priorities, agenda and principals.

At 3:49 AM, Anonymous Birth Control Options said...

Intrauterine contraceptive are apt in this scenario and have greater efficacy than even tubal ligation procedure. IUC come in duo forms, namely, Mirena which steadily release progestin and is widely advised by many obstetricians and gynaecologists. It functions by bringing about variations in mucus present in the cervix thus blocking sperms passage and their reach to the egg. Moreover, it could additionally avert ovulation. It could be safely used for about 5 years and on its removal one could conceive soon after.


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