Dr. Paula Hillard discusses contraceptive options ranging from emergency contraception to new versions of "the pill" and presents the "pro's and con's" of each method ~ June 27, 2000.
StorkNet/Mediconsult: Our guest host tonight is Paula Hillard, M.D. Dr. Hillard is an obstetrician/gynecologist at the Drake Center in Cincinnati. Welcome Dr. Hillard!
Question: What is the most effective means of birth control available today? I am confused by all the statistics. When someone says a condom is 90 percent effective, does that mean that for every 10 times I have sex, I have one chance of becoming pregnant? Exactly what does all of this mean? Also, is this the same for STD's?
Dr. Hillard: No birth control method, other than abstinence/avoiding intercourse, is 100 percent effective. Birth control methods like Depo-Provera, Norplant, and the copper IUD are the most effective forms of reversible birth control. The birth control pills, when taken perfectly, have a very low failure rate, but among "typical users" (i.e., real people who occasionally forget to take a pill, start a new pack late, forget to get the prescription refilled), the failure rate is higher. When someone quotes an effectiveness rate of "90 percent" it means that if 100 women/couples use the method for a year, 10 of them or 10 percent will have a pregnancy. With condoms, as with any other "barrier" means of birth control (the sponge, the diaphragm, the cervical cap), consistent and correct use (using a condom with every act of intercourse) will result in a higher effectiveness than will "typical" use (in which condoms are sometimes used and sometimes not). The best protection from STD's also results from consistent and correct use.
Question: My husband had a vasectomy and now I am pregnant. What are the odds of this happening and now does he need another vasectomy? How is a second vasectomy performed?
Dr. Hillard: No method of birth control is 100 percent effective, even those methods such as vasectomy and tubal ligation that are intended to be permanent. One issue with vasectomy is being sure that no sperm are present in the ejaculate -- it may take up to 15 to 20 ejaculations for this to occur, and a test of the semen to assure that no sperm are present should be done before giving up using another method of birth control. Vasectomies have a failure rate of less that one percent. Sometimes the tubes regrow or a new opening forms in the tube that lets sperm pass through.
Question: How does the "morning after" pill work and what are the positives and negatives?
Dr. Hillard: When the "morning after" pill for emergency contraception is given before ovulation, follicular development is inhibited and ovulation either doesn't occur or is delayed. When it is given after ovulation, it may act by preventing implantation of a fertilized egg. Either way, emergency contraception does not interrupt or disrupt an already-established pregnancy. It is also possible that emergency contraception may affect the transport of egg or sperm. As for positives and negatives, clearly most women would, if given the choice, prefer to prevent an unplanned pregnancy rather than decide what to do after one occurs. Many doctors feel that the biggest problem with emergency contraception is that too few people know that it is an option. One smart choice would be to ask your doctor (just in case). It has been estimated that a million abortions could be prevented each year in the U.S. if everyone who might use emergency contraception actually did. Emergency contraception is not designed to be used on a regular basis, and if a woman needs to use it she should reconsider her contraception choice.
Question: Many years ago I received a shot of Depo-Provera and had a very serious problem with my heart. My gynecologist has recommended Depo-Provera since I cannot take birth control pills and believes the previous problem was unrelated to the shot. Has the shot improved in recent years?
Dr. Hillard: Depo-Provera has been available for many, many years -- and it has been used particularly for women with special medical conditions that would make the use of birth control pills risky. It has been approved for use by healthy women in the U.S. since 1992. The likelihood that your serious heart problems were due to Depo-Provera is very, very small. One of the most reassuring things about Depo-Provera is that there have been many, many millions of women around the world who have used it safely for many, many years.
Question: What can you tell me about the female condom? Does it work? Do women like it? Do men like it?
Dr. Hillard: The female condom hasn't proven to be a blockbuster success in the U.S. in terms of sales or the percentage of women using it, but there certainly are women and their partners who have used it and continue to use it. Its efficacy is very similar to that of the diaphragm. It does represent another option for birth control and some people feel that its biggest plus is that it is "female controlled" so that if the man doesn't want to/refuses to or is unwilling to use a male condom, protection from both pregnancy and STDs can be obtained. It is also particularly valuable in some countries where there are cultural barriers that make it difficult for women to insist that their partner use a condom. One complaint that I have heard about the female condom is that it's NOISY! It tends to go 'snap, crackle, pop' which could add a little rhythm to love making.
Question: Is it true you cannot use jelly or lubrication with condoms? Why? Also, are the colored and flavored condoms as effective as regular condoms?
Dr. Hillard: There are manufacturing and testing guidelines for condoms made and sold in the U.S. that are very stringent. Condoms made and sold in other countries may not have passed such tests. So yes, the colored and flavored condoms (as long as they are latex) are comparable to the regular ones. Petroleum products, such as Vaseline -- petroleum jelly -- should not be used with condoms. Oil-based products such as baby oil, cold cream, edible oils, hand lotion, massage oil, suntan lotion, vegetable or mineral oil or vaginal yeast infection medicines should not be used with latex condoms because they can weaken the condom and increase the risk that it would break. It is ok to use a spermicidal jelly, cream, foam, suppository or other spermicidal preparation. In fact, it is recommended because it provides more protection than just the condom alone, particularly if the condom should break or slip off. Water-based lubricants such as k-y jelly, astroglide and other personal lubricants are safe to use with latex condoms.
Question: Does the female condom prevent disease transmission?
Dr. Hillard: It is certainly much better than nothing. Although there is not a lot of research to prove it, in theory, unless the female condom is torn or slips out of place, it should provide protection against infections that is at least as good as the male condom.
Question: I am breastfeeding and do not have a period. My doctor says I can still get pregnant. What is the truth?
Dr. Hillard: The truth is that "it depends". A number of studies have shown that breastfeeding can provide relative infertility. Exclusive breastfeeding (i.e., NO supplementation and breastfeeding on demand around the clock) is associated with longer periods of "lactational amenorrhea" (no periods) and infertility, than is breastfeeding with supplementation. However, the longer a woman breastfeeds, the more likely she is to resume her periods and to ovulate. In addition, ovulation can occur BEFORE the return of the first menstrual period and that possibility increases with time after delivery. So ask yourself: Am I exclusively breastfeeding? How old is the baby? How much do I NOT want to have another baby any time soon? Close pregnancy spacing isn't the healthiest for mothers (less than one year between birth and subsequent conception). Many women/couples decide to use an additional means of birth control once periods resume or the baby gets to be three to six months old.
Question: I am 46 and I still have my period, although they are further apart . . . more like 30 days. I have no symptoms of menopause yet. What should I be watching for? Am I still fertile?
Dr. Hillard: You are, technically, still fertile until one year after your last menstrual period (which incidentally, you won't know is your last until it's been a year! CATCH 22). Many of us have heard about the "menopause baby" that our mother/grandmother/great aunt or other family member thought was the "change of life" and turned out to be pregnancy, with all of its life changes. Many women in their 40's who are otherwise healthy and nonsmokers are finding that oral contraceptives provide birth control, control of irregular or heavy cycles, menstrual cramps, hot flashes and also decrease the risks of ovarian and uterine cancer. You might want to ask your doctor about this option.
Question: At what age is it best to teach a child about contraception?
Dr. Hillard: Knowledge is a good thing! And there is no evidence that sexuality education that teaches about responsible sexual activity and contraception makes it more likely that your son will become sexually active. In fact, without knowledge about contraception or protection from sexually transmitted infection, your son's health or even his life could be at risk. Answer all questions as they come up. Take all opportunities to talk about responsible sexual activity that includes birth control until a couple is ready to have a baby. Parenting should be a choice; every pregnancy should be a wanted pregnancy. Parents shouldn't wait to have "the conversation" at a certain age -- by the time the parent thinks it's time, it's usually much too late! Have multiple conversations with your children -- from the time that they learn to call their nose a "nose" and their penis a "penis", until they are adults making responsible adult choices.
Question: What is the status on the "pill" for men? What are the long-term side effects? Does it cause impotence?
Dr. Hillard: It's not yet available, and probably won't be for a long time. There are currently clinical trials of various "male methods" that may combine the hormone testosterone with another hormone such as Progestins (like Depo-Provera). These methods aren't yet practical and ways of delivering the hormones (such as implantable rods, like Norplant) are being developed. It probably won't be a "pill". It's actually pretty difficult to cause "azospermia" -- no sperm production or limited sperm production without causing other problems like impotence. That's why combination methods are being considered.
Question: If the condom and the pill are not feasible as methods of birth control, what about the birth control injection "Depo-Provera"?
Dr. Hillard: Depo-Provera is a birth control shot given every 12 weeks. It is quite effective, but often causes irregular periods and can cause other side effects such as weight gain, headaches or acne. But many women, particularly younger women, are very happy with it as a method. Very soon, another shot will be available. Unlike Depo-Provera that contains only a synthetic progesterone, the new shot will contain both an estrogen and a progestin. It will be a monthly shot, which is somewhat less convenient than every three months. However, this new shot will be associated with regular periods for most women. It should be available soon. It is very popular with Hispanic women/Latinas and is currently available in Mexico and other countries worldwide.
Question: What is emergency contraception and is it the same as the Ru-40 pill?
Emergency contraception has been an option for many, many years. Unfortunately, too few people know about it. It used to be called the "morning-after pill". The term emergency contraception is a better term as the currently available methods are effective up until 72 hours after "the event" — a broken condom, "inclination and opportunity that unexpectedly converged", unprotected intercourse, etc. However, the sooner the better, as studies show that it works better when used earlier. Emergency contraception is not the same thing as abortion that interrupts an established pregnancy. It is not entirely clear how it works, but when it is given before ovulation it disrupts normal development of the egg and follicle with a resultant delay or inhibition of ovulation. Emergency contraception may also change the lining of the uterus to impair implantation or may possibly affect the transport of the egg or sperm. Ru-486 has been used in other countries both for emergency contraception and for medical abortion, but it is not the same as the methods of emergency contraception that are currently available in this country.
Question: What are the risks to a man's health after a vasectomy?
Dr. Hillard: There have been a number of studies that have looked at whether there is any relationship between vasectomy and prostate cancer. Most of those studies, including one study that matched 10,000 men who had had a vasectomy with 10,000 men who had not, found no increased risk for prostate cancer among men who have had a vasectomy. Prostate problems, including enlargement of the prostate gland, are very common, particularly as men get older. In 1993, the National Institutes of Health asked experts to look at the issue of risk for prostate cancer and concluded that while more research would be helpful, screening for prostate cancer should be the same for men who have had a vasectomy as for those who have not.
Question: Is it true that two condoms should never be worn at the same time because it may cause tearing?
Dr. Hillard: Yes, it is true. Do not use two condoms at once, but your partner using condoms and you using a spermicide (foam, suppository, jelly, cream) does improve efficacy and would likely decrease risk of infection if the condom would break.
Question: Will being on birth control pills for many consecutive years cause any problems later with getting pregnant?
Dr. Hillard: It's one of the oldest wives' tales out there. There is no need to take a break and there's no need to worry about your fertility related to the pill. You may still want to consider your age as we all become somewhat less fertile as we get older. Many people feel that the pill actually helps to preserve fertility by decreasing the risk of pelvic infection or ovarian cysts. So if you're happy with the pill, keep going.
Question: Is there a medical reason behind physicians not wanting to perform sterilization procedures on people under 25?
Dr. Hillard: Most doctors who do sterilization procedures (either male or female) want to be very sure that the individual and/or couple have seriously considered their choice and that it is understood that these procedures are intended to be permanent. Years ago, doctors used to insist on a formula that included both the woman's age and the number of children that she had; if the numbers weren't high enough, sterilization wouldn't be done. Those formulas are no longer used, but doctors are aware of studies that suggest that younger individuals are more likely to regret their decision for sterilization and even to request that it be reversed. Finding a doctor who will do the procedure should be possible. They will just want to know that you have thought about it carefully and understand what you are doing.
Question: What are the best options for contraception for a 40-year-old woman?
Dr. Hillard: The best option for you as an individual depends on a lot of things. I might suggest that you visit the Web site of the Association of Reproductive Health Professionals -- http://www.arhp.org/iq/ -- a site that includes a quiz that will help you select a birth control method that fits your needs. One option to consider is that if you feel that you have completed your family, surgical sterilization for either you or your partner is something to consider. Certainly your gynecologist or primary clinician would be happy to discuss this with you.
Question: Are some people more fertile than others? Why do some women become pregnant while on multiple methods of birth control?
Dr. Hillard: Doctors and women sometimes joke about "fertile Myrtle" who does seem to be more fertile than average. Younger women are typically more fertile than older women. Birth control methods can fail… it may be the method itself (no method is 100 percent effective), but failures also commonly result when the method was used inconsistently ("it won't matter just this once") or incorrectly.
Question: Do women who have had tubal ligations tend to have a higher than average rate of hysterectomies later on?
Dr. Hillard: There are studies that suggest that this may be true. However, keep in mind that once a woman has had a tubal ligation, she has made the decision not to have any more children and thus she may consider a hysterectomy to be a more reasonable option than would a woman who was not certain about having more children. The other issue is that women who have had a sterilization have often stopped using another method like birth control pills. Birth control pills help control symptoms like menstrual pain, irregular periods or heavy bleeding. These are conditions that may lead to a hysterectomy.
Question: Is it normal to gain weight while taking Depo-Provera shots?
Dr. Hillard: It is true that most women do gain at least a little weight while using Depo-Provera. The average weight gain is four to five pounds per year. For some women this isn't a problem but others find it to be a major concern. In addition, some women gain more than the average. Depo-Provera is a very effective method of birth control and many women find it quite convenient. Attention to a healthy diet and an increase in your level of exercise will help keep weight gain to a minimum.
Question: Is there anything new in the area of contraception?
Dr. Hillard: There are some exciting new developments that will be available very soon. One is a monthly shot that contains both estrogen and progestin (like birth control pills), and that causes regular periods (also like birth control pills, but unlike Depo-Provera). It is very popular among Latinas and should be available very soon. It is quite effective and will be an interesting new choice. Another option that is coming relatively soon will be a new "intrauterine system" -- a device like the IUD that is inserted into the uterus that releases a synthetic form of the hormone progesterone. It is currently available (and very popular) in Europe. Unlike today's IUDs (that work really well and last for 10-12 years), this new intrauterine system won't result in any increased menstrual flow or cramps. The contraceptive sponge should be back on the market relatively soon. Non-latex condoms with new designs are being studied. New designs for diaphragm-like devices are being studied. Contraceptive implants like Norplant or vaginal rings are also being tested.
Question: Is it common to get infections from Norplant, especially when they are removed?
Dr. Hillard: Norplant is a little trickier to remove than to insert, and the ease of removal depends both on the doctor's experience with removal and on the original placement of the small rods. Infection should be a very rare occurrence, particularly among doctors who do removals frequently.
StorkNet/Mediconsult: Our thanks to Dr. Hillard!