Introduction to Contraception
The normal menstrual cycle
During fertile years women are unique in having a more or less regular
cycle of changes in their bodies. This cycle is caused by the ebb and flow
in the bloodstream of various hormones or chemical messengers which are
released into certain glands. The whole process is controlled by the brain.
Some women who have a stressful emotional upset can cause periods to stop
altogether for months. Parts of the brain involved are called the pre-optic
area and the hypothalamus. Below the brain is the pituitary gland, sometimes
called the leader of of the hormones because of its importance, which is
the size of a large pea. The ovaries and uterus are also important as blood
flows through them all connecting the whole system together. Any hormone
released into the blood by one gland can therefore travel to all the others
and can cause its own specific effects there or as appropriate anywhere
in the body.
Contraception is considered a matter of personal decision, but health
professionals have a responsibility to extend the knowledge and availability
of contraception to anyone who requests it. Responsibilities include having
appropriate training in family planning in order to give either single individuals
or couples seeking contraception, concise, factual information about the
different methods of contraception available. The doctor reviews the history
and other recommendations which may effect the person's or couple's choice.
The doctor will also validate the person's real understanding of the chosen
method, and provide explanations and interpretations if necessary, and also
discuss the pros and cons of each method. In addition, they need to aware
of the emotional, social, and religious aspects of contraception.
There are numerous methods of contraception, most of which, seem to depend
more on the woman than the man. Not only is there a difference in the way
the methods work and are used, but there is significant difference in the
protection each method provides.
A List of Contraceptive Methods with the Possibility of User failure:
- The Combined Pill
- The Progestogen only pill
- Male Condom
- Female Condom
- Diaphragm or Cap
- Natural Family Planning(NFP)
Contraceptive Methods which no user interaction:
- Contraceptive Injection
- Intrauterine System (IUS)
- Intrauterine Device (IUD)
- Female Sterilisation
- Male Sterilisation (Vasectomy)
Contraception - The Pill
If you have had unprotected sex, or you are worried that your contraception
has failed, there are two methods of emergency contraception: Emergency
pill (also known as the morning after pill), and the copper IUD (Intrauterine
Both methods are very effective if used soon after unprotected sex. The
emergency pill can be taken up to three days after sex, and this prevents
more than nine out of ten pregnancies if taken within 24 hours. However,
the later the emergency pill is taken the lower the chance of success. The
emergency pill is a single tablet that is effective within 72 hours of unprotected
sex, it releases the hormone progestogen and works in three possible ways.
- It can prevent ovulation (an egg being released in the womb)
- Delay ovulation until a safe time
- Prevent implanting (when a fertilised egg settles in the womb.
If vomiting occurs within two hours of taking the pill, it is very important
to seek advice from the Doctor about getting a repeated dose, together with
a medicine to stop the vomiting again, this should be done without delay.
Due to the way the emergency pill works, your period may be later or
earlier than expected. If there are any concerns contact the doctor again.
Although most women can use the emergency pill, women already taking other
medication will need to discuss this with the doctor first, who will advise
the best method of emergency contraception. The emergency contraception
pill should not be taken if already pregnant, as the treatment will not
work, although if it is taken when pregnant, there is no evidence to suggest
it will harm the baby.
If a copper IUD is considered, it is important to have an examination
to check for sexually transmitted infections prior to being fitted, and
if an infection such as chlamydia has been diagnosed your doctor will delay
fitting until the infection has been treated. A copper IUD will not be considered
if there is a history of a previous ectopic pregnancy (when a fertilised
egg settles in the fallopian tubes) or any other problems with the womb
or cervix. The copper IUD can be fitted into the womb by the doctor within
five days of having unprotected sex, or at the earliest time when ovulation
took place, it has almost a 100% success rate.
The emergency pill should not be relied on as a regular method of contraception.
The doctor will discuss the best option available following history taking
of each case at consultation.
Oral Contraception (the pill)
Contraceptive pills are synthetic chemical hormones which resemble the
female hormones of the ovary. In suppressing ovulation they mimic the action
of pregnancy. Protection is established as soon as the woman begins taking
the pill, if started on the 1st day of the menstrual cycle. The pills are
divided into two types, the combined pill and progestogen pill. The combined
pill contains synthetic oestrogen and progesterone hormones in each pill.
The progestogen or ( Mini-Pill) contains a progestational agent and no oestrogen.
The combined pill contains two hormones which inhibit the release of
hormones which stimulate the final development and release of ova (eggs)
from the ovary.
The combined pill is convenient and over 99 per cent effective when taken
correctly, and has many advantages ( including protection against cancer
of the womb and the ovary). Like all drugs, there health risks associated
with its use. A very small number of women will develop a blood clot which
can be life-threatening. Women who take the pill are also more at risk of
being diagnosed with breast cancer or cervical cancer. However, for the
vast majority of women the advantages of taking the pill greatly outweigh
How it works
Contains two hormones, oestrogen and progestogen, which stop ovulation.
Can reduce PMS, period pain and bleeding. Protects against cancer of
the womb and ovary.
Increased risk of breast and cervical cancer, increased risk of thrombosis
Smokers over 35 should not use it (risk of thrombosis).
The combined pill must be prescribed by a doctor or prescribing nurse,
and blood pressure should be checked regularly, as it can be associated
with a very slightly increased risk of breast cancer and thrombosis (blood
clot), it should not be prescribed for women with migraine or have had a
previous blood clot.
The progestogen-only pill contains only one hormone and stops sperm from
getting to the egg by maintaining the natural plug of mucus in the neck
of the womb. It also makes the lining of the womb thinner. It is highly
effective (99 per cent) and it is particularly useful for women who cannot
use the combined pill. It has however, to be taken regularly at the same
time each day, and can have the disadvantage of causing irregular bleeding.
How it works
Contains the hormone progestogen, which thickens the cervical mucus,
and stops sperm getting near the egg.
Can be used when breast-feeding. More suitable for older smokers than
the combined pill.
May reduce irregular periods with bleeding in between. May be less effective
in women weighing over 70 kg (11 stone).
Must be taken at the same time each day (to within three hours).
Fertility declines after the age of 35 because of the reduced quality
of the females egg's. At the stage of the perimenopause (the time around
the menopause), fertility is low though not zero. Pregnancies over the age
of 50 are rare but the oldest woman to have conceived naturally and given
birth was aged 57 years. Increased risks of complications such as miscarriage,
chromosomal disorders ( e.g. Down's syndrome), hypertension and gestational
diabetes ( diabetes developing during pregnancy) are possible.
The types of contraception available for older women are the same as
those available for younger women, and because of the reduced fertility,
many of the methods are more effective in the perimenopausal years. No contraceptive
method is contraindicated by age alone, though if you smoke, the combined
oral contraceptive pill is not recommended after the age of 35. A low dose
contraceptive can be used at this stage if you are a non-smoker, not overweight,
and generally healthy. It would suppress the irregular hormone production
from the ovaries and lead to a more regular withdrawal bleed. Some women
continue on the oral contraceptive pill up until the age of 50. Once known
to be menopausal, HRT (Hormone Replacement Therapy) is a better option because
the hormones used are natural and will be in a lower dose.
Contraception - Other Methods
Intrauterine Contraceptive system (IUS)
These small plastic T shaped devices containing the hormone progestogen.
It is inserted into the womb by GPs, at the surgery, or by nurses at family
planning clinics. The IUS prevents pregnancy in the same way as the progesterone-only
pill, is over 99 per cent effective, can be left in place for up to five
years, and can be used by women both before and after having children. Initial
side-effects can include irregular bleeding, but periods then tend to become
lighter and shorter, or stop altogether; period pain is also reduced. Like
the IUD, the IUS is removed easily by a doctor or nurse, and does not alter
sensation during intercourse following its removal.
Intrauterine Device (IUD)
The IUD is a rigid T shaped contraceptive device made from plastic and
copper that fits inside the womb (Uterus). It used to be called a coil or
a loop. It prevents pregnancy by stopping sperm and egg meeting, and it
also makes the lining of the womb unsuitable for implantation should fertilisation
The device has one or two very fine threads that come through the cervix
opening and rest on the top of the vagina.
Fitting should be done by a trained doctor or nurse. It can be done at
the Capio private clinic, GP surgery, local family planning clinic, or sexual
health clinic (GUM).
An IUD is usually fitted during your menstrual period, or some fit on
the 5th day of a period. From the moment the IUD is fitted until the time
it is taken out, you are protected against pregnancy.
The IUD is between 98-99% effective with newer, more efficient models
presenting even lower risks of failure. These contain more copper and provide
an even higher success rate.
The IUD can be used by women both before and after having children. The
IUD is not recommended for women who are at risk of acquiring a sexually
transmitted infection. It is recommended that screening for infections are
carried out prior to insertion of the IUD. The IUD can be removed easily
by a doctor or nurse who is family planning trained.
There are several different types and sizes of (IUD) The doctor will
decide suitability during examination.
Hormone Implant (for women)
One small rod containing progestogen is inserted under the skin in the
arm, usually using a local anaesthetic. It works like the progesterone-only
pill and lasts for three years. The main disadvantage is that it can cause
irregular bleeding for several months. It is over 99 per cent effective
and is easily removed in a minute or two.
Other Combined pill-type methods: other routes of delivery for hormones.
EVRA skin patch: the transdermal route. This is a skin patch delivering
hormones through the skin. Each patch is worn for seven days for three consecutive
weeks followed by a patch free week.
Hormone Injection (for women)
The hormone progestogen is given as an injection every 8 or 12 weeks,
depending on the type used. It is over 99 per cent effective and works by
stopping the ovaries producing eggs. It shares many of the advantages of
the combined pill, but can cause irregular bleeding and weight gain. Once
the injections stop it can take a year or more for periods to return to
Contraception - Barrier
The Male Condom
Society is increasingly accepting the condom as one of the normal requirements
of modern life. This has led to their wider availability and condoms can
now readily be obtained - in supermarkets, from garages, by mail order,
through slot machines, as well as in pharmacies. They are free from all
family planning clinics and genito-urinary medicine clinics. Colours, flavours
and new materials, like plastic, make interesting options. Condoms now come
in different shapes and sizes, and it is often necessary to try different
types before the right one is found. If used correctly condoms are 98 per
cent effective at preventing pregnancy and the additional advantage of providing
good protection against many sexually transmitted infections. Hermetically
sealed, the modern condom will remain usable for a long time, though always
check the expiry date. Good quality condoms will also have the CE mark and
the Kitemark. Once the seals broken they should be used quite soon as the
rubber will perish on exposure to the air and the lubricant will dry, making
it difficult to put on.
Further Information on the Male Condom
Using a condom correctly is essential for it to be effective. It should
be put on before any contact between the penis and the vagina or the genital
area, and rolled on the correct way round. Air should be excluded from the
end of the condom as it can cause it to burst or slip off. Sharp finger
nails, rings and teeth are a hazard. Only finger pulps should be used to
unroll the condom unto the penis. If extra lubrication is needed then only
a water based one should be used with rubber condoms. There is a need to
withdraw and remove the condom while the penis is still erect to avoid semen
leaking out as the penis shrinks in size.
How it works
Barrier method. The condom covers the penis and stops sperm entering
Wide choice and good availability. Provides some protection against sexually
transmitted infections. Under male control.
Need to stop to put it on. Can split or come off if not used correctly.
Need to withdraw while still erect.
Do not re-use. Must be put on before genital contact occurs. Do not use
oil based lubricants on latex condoms.
The Female Condom
The condom for women is relatively new, but there are regular users reports
that they find them favourable as do many men. Made of plastic it is larger
in diameter than the male condom and has a flexible ring at each end. The
smaller ring fits inside the vagina, while the outer, larger, ring remains
on the outside of the vagina. After ejaculation this outer ring should be
twisted to prevent escape of the sperm and the condom gently withdrawn.
Female condoms are 95 per cent effective, and also have the advantage of
providing protection against many sexually transmitted infections.
How it works
Barrier method. The condom lines the vagina and stops sperm entering.
Can be put in before sex. Provides some protection against sexually transmitted
If not inserted in advance, need to stop to put it in. Need to make sure
that the penis enters correctly.
Do not re-use. Must be put in before genital contact occurs. Expensive
to buy, but can be obtained free at some family planning clinics, and genito-urinary
The Diaphragm or Cap
How it works
A Barrier Method. A rubber or silicone cap covers the cervix to keep
sperm out of the womb. Used with spermicidal cream or jelly.
Can be put in before sex. Provides some protection against sexually transmitted
If not inserted in advance, need to stop to put it in. Can provoke cystitis
in some users.
Must be correctly fitted, the doctor or nurse will provide the correct
size, this will involve an internal examination to ensure the cap fits correctly
over the cervix, a practice diaphragm is sometimes given to familiarize
inserting at home, as some women find the cap difficult to insert.
The device must be checked every 12 months, check expiry date, check
cap size again with the doctor if there is a significant weight loss, or
weight gain. Must be inserted before genital contact occurs.
92% to 96%
Contraception - Sterilisation
This is a permanent method of contraception in which the fallopian tubes
are either cut, sealed, or blocked so that eggs cannot pass down them to
the uterus (womb). It has a failure rate of 1 in 200, making it 99.5 per
cent effective - as good as other long term reversible methods. Should it
fail, it carries a greater risk of the egg implanting in the fallopian tube
(ectopic pregnancy). As a general anaesthetic is required and the operation
is more invasive it is a more complicated and risky procedure than a vasectomy.
It is possible to reverse the operation but with very limited success, together
with an increased risk of an ectopic pregnancy.
Vasectomy (Male Sterilisation)
Vasectomy is a simple and permanent method of contraception. You don't
need permission from your partner but it makes good sense to discuss with
your partner. There is no recorded effect on enjoying sex. The testicles
continue to produce sperm but rather than being ejaculated with the semen
the sperm are reabsorbed in each testicle. Sperm therefore doesn't build
up inside the testicles. As with any surgical procedure you will have to
sign a consent form.
When it should be done
Although there is no lower age limit for vasectomy, young, childless
men need to consider this method carefully to avoid later regret. It should
therefore only be chosen by men who, for whatever reason, are sure that
they do not want children in the future. Counselling is recommended so that
other contraception options can be discussed and the procedure fully understood.
A vasectomy immediately following a birth, miscarriage, abortion, or family
or relationship crisis is usually not recommended. For further information
on how the procedure is preformed, recovery, effectiveness, and future prospects
about reversal operations can be discussed with the doctor at appointment.
Contraception - Natural Methods
Natural Method of family planning
It is only possible for your partner to conceive within 24 hours of ovulation.
However, sperm can live for several days, sex that happens up to seven days
before ovulation can result in pregnancy (this sex can even be during a
period). It is possible to estimate the fertile period by noting certain
changes in the body. Using a fertility thermometer and a chart it is possible
to detect the sudden rise in temperature of around 0.02 degrees Celsius
which occurs at ovulation.
Monitoring changes in the cervical mucus help identify the time before
and after ovulation. The mucus becomes thin, watery and clearer before ovulation,
and afterwards returns to being thicker, sticker and whiter. When practised
according to instruction, natural family planning is 98 per cent effective,
although it does take a while to learn it as a method and requires commitment
from both partners.
How it works
Fertile and infertile times in the menstrual cycle are identified.
Freedom from side-effects, awareness of fertile times can be used for
planning pregnancies as well as avoiding them.
Method must be taught by a qualified Professional. Users must abstain
from sex, or use a barrier method, during the fertile period.
There are various different methods of indicating fertility. Effectiveness
is highest when using several indicators
Up to 98%
This method consists of the male withdrawing his penis from the vagina
before ejaculation occurs and ejaculates outside the vagina. Coitus interruptus,
or withdrawal, is better than no attempt at preventing a pregnancy but it
is very unreliable. Care must be taken not to ejaculate on or near the vulva,
as sperm may make their way into the vagina and pregnancy can result.
The method requires the man to have advance awareness of ejaculation.
This control and knowledge may be difficult to establish and may require
more sexual experience than the man or couple possesses. Also, some sperm
may escape before ejaculation occurs. The method has also been criticised
for possible psychological effects. These have associated with frustration
as a result of unresolved sexual tensions on the part of one or both partners.
But if the method is accepted by both partners and orgasm and ejaculation
do occur, the resulting psychological stresses are probable minimal.
Contraception - Summary
If the pill does no suit, or if for some reason the pill needs to be
avoided, remember there are other reversible choices available which include
the patch or ring, an injectable or an implant, the IUD or IUS. A lot of
time in family planning, we, and for the most part women have to make the
decisions, with the methods available. When deciding to take the pill, and
currently this is the most effective personally controlled reversible method,
make sure it is an informed decision, and discussed with your doctor. Remember
condoms for safer sex, and consider the risk of sexually transmitted diseases
like chlamydia and (HIV)