While this election cycle is playing out, the news is currently full of  pitched discussions on contraception and women’s health.  I’m posting an article here that I wrote a few years ago that was also published in my book, “Finding Grace and Balance in the Cycle of Life: Exploring Integrative Gynecology.” 

First, the numbers. Statistics show that the average American woman wants to give birth to two children during her reproductive life. Since her fertility stretches from her teens to her upper 40’s, this represents several decades of a monthly decision about pregnancy. The Allen Guttmacher Institute reports that among the 42 million fertile, heterosexual, sexually active women who do not want to become pregnant, 89% use contraception of some type during their reproductive years.

To achieve the control of this many cycles, she must use a contraceptive method for roughly three decades.  The type of contraception is generally age-specific. Younger women mostly use condoms or birth control pills, while women over 35 years of age are more likely to use female sterilization.

Are contraceptive options uniformly safe, easy to use and available to all women and their partners who wish to use them? The short answer is no. And here’s an important point: We know that the health of both women and their children is improved when contraception is available to space pregnancies and assist in the prevention of sexually transmitted infections. We also know that the worldwide access to contraception and family planning is closely tied to promoting economic growth and social stability. But this very personal decision has been questioned and debated a lot lately – especially when the question of payment for the options is considered. The truth of our pharmaceutical pricing is that the same pack of birth control pills can be anywhere from $2.00 at a clinic to $40.00 without insurance coverage.

I’ve recognized the controversy around contraception since my early medical school days. My classmates and I all received free materials from a local organization that had a strong opinion about contraception and family planning services. As my practice experience continued, I learned how to ask questions so that I could learn at the yearly office visit if contraceptive advice was desired without offending a woman who felt contraception was not in line with her religious beliefs. There are excellent resources available through the Couple to Couple league for natural family planning information. (www.ccli.org) If this appeals to you, stop reading now. The rest of the article is for women or couples who do not want to rely on this method of family planning.

Women have an array of methods for preventing pregnancy. Barrier methods such as male condoms are widely available and relatively inexpensive. Their first year contraceptive failure rate can vary from 2% in a “perfect user” to 17.4% in a “typical user”. Condoms can decrease (although not eliminate) the spread of sexually transmitted infections. They are relatively easy to use with rare side effects. A female condom has been on the market for a few decades; its cost ($4.00) is roughly four times the price of a male condom.

The FDA first approved the birth control pill in the 1960’s. The formulation and strength of synthetic estrogens and progestins have varied from pill to pill. The first year contraceptive failure rate for the pill varies from 0.3% for a perfect user to 8.7% for an average user. The pill works by adding synthetic estrogen and progestin hormones throughout a menstrual cycle to mimic early pregnancy and prevent ovulation or egg release during the cycle. In addition to preventing pregnancy, there are also non-contraceptive benefits to using the pill. The lifetime risk of ovarian cancer is decreased in women who have used the pill for at least three months. Menstrual cycles are lighter; menstrual cramps are less intense for women on the pill. The pill can also effectively treat acne and some other skin conditions.

On the other hand, there are downsides to the pill. There is an increased risk of blood clots and stroke in pill users – this risk increases in smokers. The pill is less effective in women with a body mass index (BMI) over 27 (equivalent to a 5’4” tall woman weighing 160 pounds or more). In addition, the lower dose pills require a regular pill-taking routine. Lower hormone levels from missing a pill, taking it late or taking a medication that increases the clearance of the hormones from the body can lead to spotting and/or an unplanned pregnancy. The birth control pill does not prevent sexually transmitted diseases.

Because of the inconvenience of daily pill consumption, drug manufacturers have offered three month injections, five year implants (no longer on the market), vaginal rings, and patches (no longer on the market). There is also a formulation that skips the “monthly” cycles and change the bleeding pattern to quarterly.

Intrauterine devices (IUD’s) are designed to prevent pregnancy by mainly preventing fertilization (changing cervical mucous to prevent sperm penetration). There are currently two types of IUD’s on the market. They’re inserted in the uterus during a pelvic exam in your physician’s office. Most women who choose the IUD like the convenience and have had at least one child. The disadvantages of the method are the risk of infection and potential sterility. The risk is essentially non-existent when both partners are monogamous and committed to the relationship.

Tubal ligation and vasectomy can be performed once a couple’s family size is complete. The failure rates are low for both procedures; risks are slightly higher for tubal ligation because it is done at a surgery center with general anesthesia while the vasectomy is done in the physician’s office with local anesthesia. Permanent sterilization shouldn’t be scheduled unless a couple is certain that they never want to conceive.

All the contraceptive options have risks and benefits. Ideally it’s a shared decision after a thorough review of options by your physician, nurse practitioner or midwife. It is NOT, however, a decision that should be made by your Senator or Congressman or President!