Peter T. Simonson, MD, PLLC
Obstetrics and Gynecology
Patient information: Birth control; which method is right for me?
Author
Mimi Zieman, MD
Section Editor
Robert L Barbieri, MD
Deputy Editor
Vanessa A Barss, MD
Last literature review version 18.2: May 2010 | This topic last updated: September 1, 2009 (More)
INTRODUCTION — There are a number of methods available to help prevent pregnancy, with some of the most popular including condoms and birth control pills. Deciding which method is right can be tough because there are many issues to consider, including costs, future pregnancy plans, side effects, and others.
This article reviews all methods of birth control. More detailed discussions of hormonal, long-term, and barrier birth control methods are available separately. (See "Patient information: Long-term methods of birth control" and"Patient information: Barrier methods of birth control" and "Patient information: Hormonal methods of birth control".)
EFFECTIVENESS OF BIRTH CONTROL — Most birth control methods are quite effective if used properly. However, contraceptives can fail for a number of reasons, including incorrect use and failure of the medication, device, or method itself.
Certain birth control methods, such as intrauterine devices (IUDs) and injectable or implanted methods, have a low risk of failure (pregnancy). This is because they are the easiest to use properly. You should consider these methods if you want the lowest chance of a mistake or failure, which could lead to pregnancy. (See "Patient information: Long-term methods of birth control".)
Overall, birth control methods that are designed for use at or near the time of sex (eg, the condom, diaphragm) are generally less effective than other birth control methods (eg, IUD, birth control pill).
If you forget to use birth control or if your method fails, there is an option to reduce your risk of becoming pregnant for up to 5 days after you have sex. This is called the morning after pill, or emergency contraception. (See "Patient information: Emergency contraception (morning after pill)".)
CHOOSING A BIRTH CONTROL METHOD — It can be difficult to decide which birth control method is best because of the wide variety of options available. The best method is one that you will use consistently, is acceptable to you and your partner, and does not cause bothersome side effects. Other factors to consider include:
- How effective is the method?
- Is it convenient? Will I remember to use it?
- Do I have to use/take it every day?
- Is this method reversible? Can I get pregnant immediately after stopping it?
- Will this method cause me to bleed more or less?
- Are there side effects or potential complications?
- Is this method affordable?
- Does this method protect against sexually transmitted diseases?
No method of birth control is perfect. You must balance the advantages and disadvantages of each method and then choose the method that you will be able to use consistently and correctly.
EMERGENCY CONTRACEPTION — Emergency contraception, also called the morning after pill, refers to the use of medication to prevent pregnancy. You can use the morning after pill if you forget to take your birth control pill, if a condom breaks during sex, or if you have unprotected sex for other reasons (including victims of sexual assault). Detailed information on emergency contraception is available separately. (See "Patient information: Emergency contraception (morning after pill)".)
BIRTH CONTROL PILLS — Most birth control pills, also referred to as "the pill," contain a combination of two female hormones. A list of available pills is shown in the table (table 1). A full discussion of birth control pills is available separately. (See "Patient information: Hormonal methods of birth control".)
How well do they work? — When taken properly, birth control pills are very effective. In general, if you miss one pill, you should take it as soon as possible, If you miss two or more pills, continue to take one pill per day and use a back-up method of birth control (eg, a condom) for seven days. If you miss two or more pills, you should also consider taking the morning after (emergency contraception) pill. (See "Patient information: Emergency contraception (morning after pill)".)
Side effects — Side effects of the pill include:
- Nausea, breast tenderness, bloating, and mood changes, which typically improve after two to three months.
- Irregular vaginal spotting or bleeding. This is particularly common during the first few months. Forgetting a pill can also cause irregular bleeding.
Progestin-only pills — Unlike traditional birth control pills, the progestin-only pill, also called the mini pill, does not contain estrogen. It does contain progestin, a hormone that is similar to the female hormone, progesterone. This type of pill is useful for women who cannot or should not take estrogen. This includes women who are breastfeeding or who have worsened migraines or high blood pressure with estrogen-containing birth control pills.
Progestin-only pills are as effective as combination pills if they are taken at the same time every day. However, progestin only pills have a slightly higher failure rate if you are more than three hours late in taking it.
INJECTABLE BIRTH CONTROL — The only injectable method of birth control currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera®). This is a progestin hormone, which is long-lasting. DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months. A version that is given under the skin is also available.
DMPA is very effective, with a failure (pregnancy) rate of less than one percent. A full discussion is available separately. (See "Patient information: Hormonal methods of birth control".)
Side effects — The most common side effects of DMPA are irregular or prolonged vaginal bleeding and spotting, particularly during the first three to six months. Up to 50 percent of women completely stop having menstrual periods after using DMPA for one year. Menstrual periods generally return within six months of the last DMPA injection.
SKIN PATCHES — Birth control skin patches contain two hormones, estrogen and progestin, similar to birth control pills. The patch is as effective as birth control pills, and may be preferred by some women because you do not have to take it every day.
Ortho Evra is the only skin patch birth control available in the United States. You wear the patch for one week on the upper arm, shoulder, upper back, or hip. After one week, you remove the old patch and apply a new patch; you repeat this for three weeks. During the fourth week, you do not wear a patch and your menstrual period occurs during this week.
The risks and side effects of the patch are similar to those of a birth control pill, although there may be a slightly higher risk of developing a blood clot.
VAGINAL RING — A flexible plastic vaginal ring (Nuvaring®) contains estrogen and a progestin. You wear the ring in the vagina, where there hormones are slowly absorbed into the body. This prevents pregnancy, similar to a birth control pill. You wear the ring inside the vagina for three weeks, followed by one week when you do not wear the ring; your menstrual period occurs during the fourth week.
The ring is not noticeable, and it is easy for most women to insert and remove. You may take the ring out of the vagina for up to three hours if desired, such as during intercourse. Risks and side effects of the vaginal ring are similar to those of birth control pills.
BIRTH CONTROL IMPLANT — A single-rod progestin implant, Implanon®, is available in the US and elsewhere. It is inserted by a healthcare provider into your arms. It prevents pregnancy for up to 3 years as the hormone is slowly absorbed into the body. It is effective within 24 hours of insertion. Irregular bleeding is the most bothersome side effect. Most women can become pregnant quickly after the rod is removed. (See "Patient information: Hormonal methods of birth control".)
BARRIER METHODS — Barrier contraceptives prevent sperm from entering the uterus. Barrier contraceptives include the condom, diaphragm, and cervical cap. A full discussion of barrier methods of birth control is available separately. (See "Patient information: Barrier methods of birth control".)
Male condom — The male condom is a thin, flexible sheath placed over the penis. To be effective, men who use condoms must carefully follow instructions for their use. Condoms are most effective when used with a vaginal spermicide (see 'Spermicide' below). Using the male condom and a vaginal spermicide is as effective as a hormonal method of birth control, and is more effective than a condom alone.
Many people who choose another method of birth control (eg, pills) also use condoms to decrease their risk of sexually transmitted diseases.
Female condom — The female condom is worn by a woman to prevent semen from entering the vagina. It is a sheath made of polyurethane, and is prelubricated. You wear it inside the vagina.
Diaphragm/cervical cap — The diaphragm and cervical cap fit over the cervix, preventing sperm from entering the uterus. These devices are available in latex (the Prentif cap) or silicone rubber (FemCap) in multiple sizes, and require fitting by a clinician. These devices must be used with a spermicide and left in place for six to eight hours after sex. The diaphragm must be removed after this period. However, the cervical cap can remain in place for up to 24 hours.
Spermicide — Spermicides are chemical substances that destroy sperm. They are available in most pharmacies without a prescription. Spermicides are available in a variety of forms including gel, foam, cream, film, suppository, and tablet.
INTRAUTERINE DEVICES (IUD) — IUDs are inserted by a healthcare provider through the vagina and cervix, into the uterus. The currently available IUDs are safe and effective. These devices include:
- Copper-containing IUDs prevent pregnancy by preventing sperm from reaching the fallopian tubes. Copper-containing IUDs remain effective for at least 10 years. Copper IUDs do not contain any hormones. Some women have a heavier menstrual period while using a copper IUD.
- Levonorgestrel-releasing IUDs prevent pregnancy by releasing a hormone, levonorgestrel, which thickens the cervical mucus and thins the endometrium (the lining of the uterus). This IUD also decreases the amount you bleed during your period and decreases pain associated with periods. It can be left in place for up to five years, and is highly effective in preventing pregnancy. Some women stop having menstrual periods entirely; this effect is reversed when the IUD is removed.
STERILIZATION — Sterilization is a procedure that permanently prevents you from becoming pregnant or having children. Tubal ligation (for women) and vasectomy (for men) are the two most common sterilization procedures. Sterilization is permanent, and should only be considered after you discuss all available options with a healthcare provider. (See "Patient information: Permanent sterilization procedures for women" and "Patient information: Vasectomy".)
Tubal ligation — Tubal ligation is a sterilization procedure for women that surgically cuts, blocks, or seals the fallopian tubes to prevent pregnancy. The procedure is usually done in an operating room as a day surgery. Women who have recently delivered a baby can undergo tubal ligation before going home. The procedure may be done at another time as well. A separate article discusses tubal ligation. (See "Patient information: Permanent sterilization procedures for women".)
Essure® — Essure® is a permanent birth control method in which a tiny coil is placed into a woman's fallopian tubes. The tissue within the fallopian tubes grows into the coil, blocking them three months after placement in most women. The coil is placed after you are given local anesthesia (medicine is injected into the cervix to prevent pain). A back up method of birth control (eg, pills, condoms) is needed until you have a test confirming that the fallopian tubes are completed blocked; this is usually performed three months after coil placement.
Vasectomy — Vasectomy is a sterilization procedure for men that cuts or blocks the vas deferens, the tubes that carry sperm from the testes. It is a safe, highly effective procedure that can be performed in a doctor's office under local anesthesia. Following vasectomy, you must use another method of birth control (eg, condoms) for approximately three months, until testing confirms that no sperm are present in the semen. A separate article discusses vasectomy. (See "Patient information: Vasectomy".)
OTHER BIRTH CONTROL METHODS — Some women and their partners cannot or choose not to use the birth control methods mentioned above due to religious or cultural reasons. Alternate birth control options include periodic abstinence and withdrawal.
Periodic abstinence — Periodic abstinence involves trying to predict the time of the month when a woman is most fertile and not having sex during that time. Different methods can help determine your fertile period:
Rhythm or calendar method — The rhythm or calendar method uses the date of your last menstrual period to determine your most fertile period.
- The first day of the fertile period is calculated by subtracting 18 days from your shortest menstrual cycle.
- Your menstrual cycle is defined as the number of days from the start of one period to the start of the next period (usually 21 to 30 days).
- The last day of your fertile period is calculated by subtracting 11 days from the length of your longest menstrual cycle.
For example, if your menstrual cycle is 28 to 30 days, you should refrain from sex from days 10 to 19 of each cycle. Day 1 is the first day of bleeding.
This method is not recommended if you have irregular menstrual cycles or if you have recently delivered a baby or are breastfeeding.
Basal body temperature — This method is based upon changes in body temperature that occur during your menstrual cycle. You take your temperature with a basal thermometer before getting out of bed in the morning; this is called the basal body temperature. Your basal temperature will rise slightly (about 0.5º F) after release of the egg.
You should avoid having sex between the start of your menstrual cycle (day one) until three days after your temperature rises. For most women, this requires not having sex for two weeks. This method is not recommended for women who breastfeed or are nearing menopause.
Cervical mucus — You can use the color, amount, and consistency your cervical mucus, which change through the menstrual cycle, to determine when you are ovulating. During ovulation, the mucus is typically watery and heavier than at other times. You should avoid sex when watery cervical mucus first appears until three to four days after the heaviest day of mucus.
When used perfectly, basal body temperature plus cervical mucus monitoring methods are more effective than the calendar or rhythm method. However, failure rates may be as high as 86 percent (with a 28 percent risk of pregnancy per cycle) if these methods are used incorrectly.
Withdrawal — Also known as coitus interruptus, the withdrawal method requires the man to withdraw his penis from the vagina before ejaculation. Pregnancy may occur if withdrawal occurs too late or if sperm is released before orgasm (in fluid released before ejaculation). With this method, failure rates may be as high as 18 to 20 percent.
Breastfeeding — Breastfeeding after childbirth is somewhat effective in preventing pregnancy because it can delay the return of ovulation. Approximately 88 percent of women who breastfeed exclusively (meaning that no formula is given and the baby is fed on demand) do not ovulate for six months. If you do not have a menstrual period and you are breastfeeding exclusively, you are more than 98 percent protected from pregnancy for the first six months. Women who use supplemental feeding (formula) and those who have menstrual periods are more likely to ovulate.
A healthcare provider can help to determine the best timing and form of birth control following childbirth. (See"Patient information: Maternal health and nutrition during breastfeeding".)
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed every four months on our web site (www.uptodate.com/patients).
Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information
Patient information: A guide to birth control (contraception)
Patient information: Long-term methods of birth control
Patient information: Barrier methods of birth control
Patient information: Hormonal methods of birth control
Patient information: Emergency contraception (morning after pill)
Patient information: Permanent sterilization procedures for women
Patient information: Vasectomy
Patient information: Maternal health and nutrition during breastfeeding
Professional level information
Approach to intrauterine contraception
Contraception counseling for obese women
Contraception for women with inherited thrombophilias
Contraception: Overview of issues specific to adolescents
Counseling women seeking hormonal contraception
Depot medroxyprogesterone acetate for contraception
Emergency contraception
Female condoms
Fertility awareness-based methods of pregnancy prevention
Hormonal contraception for suppression of menstruation
How to fit and use a diaphragm for contraception
Hysteroscopic sterilization
Implanon
Male condoms
Management of problems related to intrauterine contraception
Management of unscheduled bleeding in women using contraception
Overview of contraception
Overview of the use of estrogen-progestin contraceptives
Overview of vasectomy
Postpartum and postabortion contraception
Progestin-only pills (minipills) for contraception
Risks and side effects associated with estrogen-progestin contraceptives
Surgical sterilization of women
Transdermal contraceptive patch
Vasectomy and other vasal occlusion techniques for male contraception
Patient information: A guide to birth control (contraception)
The following organizations also provide reliable health information.
- National Library of Medicine
(www.nlm.nih.gov/medlineplus/birthcontrol.html, available in Spanish)
- National Institute of Child Health and Human Development (NICHD)
Toll-free: (800) 370-2943
(www.nichd.nih.gov/health/topics/contraception.cfm)
- National Women's Health Resource Center (NWHRC)
Toll-free: (877) 986-9472
(http://www.healthywomen.org/healthcenter/birth-control)
- Planned Parenthood Federation of America
Phone: (212) 541-7800
(www.plannedparenthood.org/health-topics/birth-control-4211.htm)
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REFERENCES
1. Kost, K, Singh, S, Vaughan, B, et al. Estimates of contraceptive failure from the 2002 National Survey of Family Growth. Contraception 2008; 77:10.
2. Moreau, C, Cleland, K, Trussell, J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception 2007; 76:267.
3. Trussell, J, Wynn, LL. Reducing unintended pregnancy in the United States. Contraception 2008; 77:1.
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