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Duluth experts break down birth control methods

Advanced practice registered nurse Nikki Shockley discusses birth control options using a patient education sheet at Planned Parenthood last week. Tyler Schank / tschank@duluthnews.com

EDITOR'S NOTE: This story contains important medical information about a wide variety of birth control options. It contains some explicit sexual language that some readers might want to be aware of before reading.

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Pills, patches, shots, there are many options for birth control today — and many reasons to start it.

Women and teens use some form of contraception for a variety of reasons, and only one of them is pregnancy prevention, said Dr. Kelly Greenleaf, obstetrician and gynecologist at Essentia Health.

As well as pregnancy prevention, hormonal birth control is used for period regulation, to ease heavy or painful periods and menstrual migraines, for acne issues, and to reduce the risk of uterine cancer or ovarian cysts.

It's also used to treat certain symptoms of PCOS (polycystic ovarian syndrome) and endometriosis, and some options can reduce or eliminate the need for procedures such as hysterectomies down the road, Greenleaf said.

Many forms do come with symptoms — such as spotting (light bleeding between periods) or headaches — and not all choices are right for everyone. That's why it's important to discuss risks and benefits with a professional, said Nikki Shockley, nurse practitioner at Planned Parenthood in Duluth. She also noted that other than condoms, these methods do not protect against sexually transmitted infections (STIs).

Here's an overview of some hormonal and nonhormonal birth control options, and family planning methods.

USED EVERY TIME

Male condoms

Condoms are thin sheaths worn on a penis during intercourse, oral or anal sex. They can break or come off during sex, but when used correctly and with no surprises, condoms are effective at preventing STIs, pregnancy and the transmission of HIV.

Male condoms are easily accessible without a prescription in stores, health centers and at Planned Parenthood.

Spermicide

Spermicide is a cream, gel, foam, film, tablet or suppository that's inserted in the vagina before sex. It kills sperm or stops it from moving and from entering the uterus.

Used alone, it's not an effective form of birth control. It's most effective when used with a barrier method, i.e. a condom, sponge, cervical cap or diaphragm (see below).

Spermicide can be purchased over the counter.

Diaphragm

A diaphragm is a nonhormonal, soft, silicone cup that's bent in half and inserted in the vagina before intercourse. It covers the cervix and is used with spermicide to kill sperm and prevent pregnancy. It should stay in for at least six hours after sex, but should be removed within 24 hours.

Women are fitted for a diaphragm to best fit their bodies, and a prescription is required.

The diaphragm is making a comeback, said Nyssa Krause, Planned Parenthood clinic supervisor. She attributes its resurgence to its lack of hormones.

Cervical cap

This is a soft, silicone cup that's inserted to cover the cervix before sex — like the diaphragm but smaller and shaped like a sailor hat. A cervical cap is most effective when used with spermicide.

It can stay in as long as two days — longer than a diaphragm — but the latter is more effective at preventing pregnancy. "You need perfect placement," said Shockley. There's a bigger chance for human error with a cervical cap than with a diaphragm.

Sponge

This is a polyurethane foam disk that contains spermicide and is inserted before sex, covering the cervix. It's held in place by the vaginal muscles, and it has a strap for easy removal.

It can be inserted as early as 24 hours before sex. It should be kept in the vagina for six hours afterward, and it can stay as long as 24.

The pill

There are two types: combination pills that contain hormones estrogen and progestin, and progestin-only pills. The latter are called "the mini pill," and they're recommended for women who cannot use estrogen — due to a history of blood clots or migraines with aura, those who smoke over the age of 35, or those who have uncontrolled high blood pressure.

Much like with other contraception, the pill suppresses ovulation and thickens cervical mucus.

These are taken daily, and oral contraception can be difficult because of the necessary routine. With progestin-only pills especially, it's important they're ingested at the same time every day.

If you don't take it on schedule, you will likely ovulate, Greenleaf said.

It can take up to three months for the menstrual cycle to regulate after starting a hormonal contraceptive, but there are different doses and types to try if one isn't working, Krause said.

Combined-hormone contraceptives suppress ovarian function and reduce the risk of ovarian cancer. The pill binds with testosterone, reducing symptoms of PCOS like acne and facial and abdominal hair growth, Greenleaf said.

The patch

The transdermal contraceptive patch is applied to a nonfatty part of the body, and hormones estrogen and progestin are absorbed through the skin. Most women choose to apply the patch on the lower abdomen or the back of their shoulders, Greenleaf said.

The patch is changed weekly for three weeks, no physician required. And like the pill, it stops ovulation and thickens the cervical mucus, preventing pregnancy by creating an obstacle between sperm and egg, according to mayoclinic.org.

The ring

The NuvaRing is soft, pliable plastic inserted into the vagina. Like the pill, the ring emits hormones estrogen and progestin. It stays in for three weeks, and is removed during menstruation. "It's much easier than a tampon," Greenleaf said of its application.

"Girls have to be comfortable with their own bodies to be able to use the ring," Shockley said. "If they're not willing to put something inside of them, then it's not a good fit."

Shockley added that the ring is well-tolerated, and it isn't as invasive as other options.

It's also a more expensive option because it's name-brand and there are no other versions, said Krause.

The ring must be changed on a schedule to effectively prevent pregnancy.

The shot

The depo shot (Depo-Provera) is administered every three months. It contains progestin, which prevents ovulation and thickens mucus on the cervix.

Many experience lighter periods with the depo shot; and some women experience no period at all.

Other than condoms, these options do not protect against sexually transmitted infections, so she stressed education and preparedness. Ask questions about risks, benefits. "A lot of women don't realize they're good candidates for birth control for various reasons," she said.

LOW MAINTENANCE

The implant

Nikki Shockley shows an etonogestrel implant. The 1½-inch implant can prevent pregnancy for up to three years. (DNT)Nexplanon is a 1½-inch progestin-releasing plastic rod. It's inserted under the skin near the bicep, commonly in the nondominant arm. It has the same effect of birth control pills, stopping ovulation and thickening cervical mucus.

It can stay in the arm for up to three years, and it can come out at any time.

IUDs

Intrauterine devices — or intrauterine contraception — are flexible, T-shaped pieces of plastic inserted in the uterus.

"IUDs are the most effective contraceptive aside from male or female sterilization," said Greenleaf.

Paraguard is a nonhormonal copper IUD that can stay in for 10 years, according to Paragard.com. How it works: the copper coils create an inflammatory reaction toxic to eggs and sperm, according to mayoclinic.org.

Women can experience heavier and crampier periods with a copper IUD.

Hormonal IUDs emit progestin or levonorgestrel, which partially suppress ovulation. They can initially cause some irregular bleeding, but it can also lead to a much lighter period, Greenleaf said.

A progestin-containing IUD can reduce the risk of endometrial (uterine) cancer by reducing the buildup of lining in the uterus.

After an implantation, women can feel for wire strings near the cervix to ensure the IUD is in place. You shouldn't be able to feel the strings during exercise, while using a tampon, nor should your partner feel them during sex. "They're not going to be hanging out down below and tickling your knees. I've had that question," said Shockley.

IUDs can be removed at any time by a physician.

LIFESTYLE

Fertility awareness, natural planning

Fertility awareness is using a condom or abstaining from sex on days you are most fertile. It's not 100 percent, but nothing is, Shockley said.

She and Krause don't see questions about these options often at Planned Parenthood.

Education on this is not something they provide as much as information about other methods. When they do field questions about natural planning, women already have a really good idea of what they're doing, and they're typically looking for confirmation, Krause said.

Withdrawal (pulling out)

This is pulling the penis out and away from the vagina and the woman's genitals before climax to prevent sperm from entering the uterus. This requires self-control and is not an effective form of birth control, as sperm may enter the vagina in pre-ejaculation fluid or if withdrawal isn't well-timed.

"That's not a great option," Shockley said, adding that a discussion about this often leads to talk of other birth control methods to prevent pregnancy.

'Outercourse,' abstinence

These can mean different things to different people, but generally, "outercourse" is sexual engagement outside of penetrative sex, and abstinence is the absence of sex. That can be the lack of oral, vaginal or anal sex, and for some, it means avoidance of vaginal sex, while other activities are a go.

Abstinence essentially keeps semen from the vagina, and practiced 100 percent of the time, this prevents pregnancy.

The same works for outercourse, which can include discussing fantasies, kissing, massage, masturbating, petting and grinding. For some people, this could include oral or anal sex, neither of which will lead to pregnancy unless semen accesses the vagina.

The latter doesn't protect against STIs, so condoms are still recommended.

Safety and preparedness are always discussed, and abstinence should always be considered, Greenleaf said, but often, when patients see her, that option is "out the window," and they're looking for other methods.

She's there to help patients make good choices, and she gives them all of their choices, but abstinence isn't recommendable, she said.

"Wait until you're ready, until you feel safe. Those are things that I recommend, not abstinence," she said. "I recommend being prepared; I tell women they should have condoms with them at all times. Don't expect the man to have it."

PERMANENT

Sterilization

For men, vasectomies are a minor surgery that cuts and blocks the tubes that carry sperm, preventing it from leaving the body. While semen is still ejaculated during climax, it's missing sperm to fertilize an egg.

Vasectomies are intended to be permanent, and while they can sometimes be reversed, it's not guaranteed, according to the Mayo Clinic.

In female sterilization, tubal ligation is a surgical procedure that permanently blocks the fallopian tubes; and salpingectomy is a laparoscopic procedure wherein one or both fallopian tubes are removed, said Greenleaf. Both are permanent forms of sterilization for women.

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Planned Parenthood has state funding sources and grants that help provide family planning and screening services across the board. If a patient's insurance covers only a certain portion, if they don't have insurance or if they make too much to qualify for other funding streams, there are options, Krause said.

Greenleaf anticipates the development of more nonhormonal options in the future, as well as male contraception besides condoms.

Going forward in selecting a method, for whatever reason, be sure you have a health care provider you trust. Come in, get an expert perspective, so you can make an informed choice together, they said.

Added Shockley: "Ask the questions; don't be afraid."

• More info: www.plannedparenthood.org/learn/birth-control

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Common misconceptions

Many clients worry that any form of contraception will affect fertility long-term; that's not true, said Nikki Shockley, nurse practitioner at Planned Parenthood in Duluth.

Along with birth control visits, she conducts screenings for cervical cancer and STIs (sexually transmitted infections), symptoms checks for UTIs or yeast infections — among other things.

The nature of a birth control visit is education and, if a patient chooses, to honestly assess choices that best suit their lifestyle.

If patients aren't going to be successful with a daily pill, there are other options, said Nyssa Krause, Planned Parenthood clinic supervisor.

People have the idea all types of birth control lead to all symptoms, and that's not true, said Dr. Kelly Greenleaf, obstetrician and gynecologist at Essentia Health.

People also confuse the morning after pill Plan B with an abortion pill; this is incorrect. It is not used during an established pregnancy. Rather, it's a safe emergency contraception, which can lower the chance of pregnancy by 75-89 percent when taken in the first 72 hours after unprotected sex. It contains levonorgestrel or ulipristal acetate, which delays or prevents ovulation, and it makes the uterus an uncomfortable place for sperm to survive.

"Accidents happen, things happen with birth control, and it's another line of defense if pregnancy is not something they want now," Krause said.

Melinda Lavine

Lavine is a features and health reporter for the Duluth News Tribune. 

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