Birth Control -What Are Your Options Besides 'the Pill'? Part 2

This is Part 2 of a 2 part article series on birth control options besides the birth control pill. Part 1 explored hormonal and copper IUDs. Part 2 will cover the ring, the patch, the diaphragm, condoms, and the fertility awareness method

“The Ring” and “The Patch”

The ring and the patch are two variations on the combined oral contraceptive pill and therefore have much the same risks, side effects and contraindications as “the pill”1. Products such as the NuvaRing and Evrapatch deliver female hormones (both estrogen and progestin) for three weeks to block ovulation and prevent pregnancy1. The ring is inserted into the vagina whereas the patch is placed on the skin. After three weeks of hormone delivery, the ring or skin patch is removed and allows for a withdrawal bleed that imitates a period, like the oral contraceptive pill. These methods work differently than the Mirena because the method of action is to block ovulation and does not necessarily modify the cervical mucus or uterine lining. With perfect use, both the ring and the patch are 99.7% effective at preventing pregnancy and with typical use, 92%2.

The Diaphragm

This is a barrier method that involves no hormones and no future impact on fertility. The diaphragm is a flexible latex or silicone dome-shaped device filled with spermicide and inserted into the upper vagina covering the cervix. It creates a spermicidal barrier at the cervical opening and must be used with the spermicidal gel to be effective. Women can insert the diaphragm up to 6 hours before intercourse and should leave it in place for at least 6 hours after (up to 24 hrs)1. If there is more than one occurrence of intercourse in the 24 hours without removal, more spermicidal gel can be added to be sure. Used correctly and consistently, the diaphragm is 94% effective at preventing pregnancy, though with typical use is 84%. For full effectiveness, the diaphragm does require active participation from the woman: proper hygiene habits and regular insertion, cleaning, removal and storage. Using a diaphragm may increase the incidence of urinary tract infections due to the manual insertion and removal. In the past, it needed to be fitted by a physician as well to ensure comfort and effectiveness. Up to 25% of married women in 1955 were using the diaphragm19, but when the birth control pill was introduced and women had the option to have contraception with much less maintenance, the popularity of the diaphragm dropped dramatically. According to the Canadian National Contraception Survey in 2009, only 0.2% of women using contraception choose the diaphragm4. ^[4] Due to its lowered popularity, there has been limited access to the diaphragm in Canada in recent decades. However, more women are now looking for alternatives to hormonal treatment and the diaphragm is seeing resurgence. New diaphragm products are coming onto the market that are designed to manage some of the drawbacks to the old designs. A new product called Caya, for example, is designed to fit most women and eliminates the need for fitting by a physician. The advantages remain the same as other barrier methods: no hormonal modification or changes to fertility of either party, and the disadvantages are relative to other methods available; the diaphragm requires more active participation from the woman but with proper use is just as effective as using male condoms2.

Male condoms, with and without spermicide

The use of male condoms is one of the most common methods of birth control. With perfect use it is 98% effective at preventing pregnancy, though this rate drops to 85% with typical use2. Perfect use means applying the condom before any sexual contact, being sure that it does not slip or tear, and removing it immediately after male ejaculation - and this must be done consistently and correctly every single time. Therefore, technique and consistency is key for this method - it requires commitment from both you and your partner to ensure you are both as protected as possible. Using additional spermicidal gel or foam can increase the effectiveness of this method, though it’s not confirmed exactly how effective typical use with extra spermicidal protection is. The advantage of condoms is that it is hormone-free and also very effective at protecting against sexually transmitted infections and HIV. It is a lifestyle choice that requires engagement from the male partner and can offer opportunity to talk about sexuality, safety and concerns with each other. Note that it is important not to use latex-based lube with latex condoms or to use two condoms at once as both of these may increase the risk of breakage2.

Fertility Awareness Method (Rhythm Method)

Fertility Awareness is a way to predict your body’s fertile and infertile times during your cycle. Based on the knowledge that the body shows visible and detectable signs of hormonal changes throughout the cycle, a female can know the date of ovulation, and therefore, know when they are fertile and when they are not. During the fertile periods during the cycle, one must abstain completely from sex or use another effective method to prevent pregnancy. This is a wonderful way to get to know your body as you track cycles and get in touch with what is happening and when. It can be extremely effective if you are diligent and consistent. With theoretical perfect use (meaning you are very good at knowing exactly when you ovulate) it is 95-97% effective. However because this method requires consistent and careful monitoring, typical use falls to about 75%2.

Making an Informed Decision^[2]

The fertility awareness method is based on the fact that an egg is released once in each menstrual cycle, usually around mid-cycle, and can live for 12 to 24 hours, waiting to be fertilized before menses flushes out the egg and the uterine lining. Sperm can live in the female reproductive tract up to 6 days and fertilize an egg. Therefore, a female is fertile for as long as six days before ovulation and two or three days after ovulation, a total of seven to eight days of fertility in her cycle each month5. During these fertile days, other contraceptive methods must be used, and outside these days, she is considered infertile and unable to become pregnant. Of course, this method does not protect against sexually transmitted infections. There are different approaches to detecting ovulation that are available to learn, including using a calendar to track cycles, assessing cervical mucous thickness, checking basal body temperature daily, and breast tenderness5. Keep in mind that your cycle itself can vary depending on many factors such as stress, change, trauma, illness and allergic reactions, making it sometimes difficult to be certain of timing. If you are interested in the fertility awareness method, be sure that both you are your partner(s) are committed and there is consistency in the tracking. If done properly this is a natural and effective way to prevent pregnancy.

Birth control is an important and intimate decision. If you are looking for alternatives to the oral contraceptive pill, know there are options available for you. Your body does not have to follow any method but what is right for you. Talk with your health care provider about your options, be informed of all the effects of each method and determine what is safe and comfortable for you at this time in your life.

Relative Effectiveness of Birth Control Methods at Preventing Pregnancy[2]