CONTRACEPTION

It’s always a good idea to discuss contraception (and sexually transmitted infections) with your partner before you get jiggy with it.

If you can’t discuss contraception and/or keeping yourselves safe with sex, you might like to check out our relationship section.

Condoms

The good old condom is the quickest, easiest and most reliable way to prevent pregnancy AND sexually transmitted infections without taking any medication.

Condoms are cheap, readily available – you can buy them at the pharmacy or supermarket, some sometimes even vending machines sell them. Store them in a cool, dry place (your wallet is possibly not the best place).

Condoms are about 98% effective if used correctly (as above), have a failure rate of 13% if not (WHO, 2020). The single biggest failure rate of condoms comes around because they have passed their use-by date.

Check out this video for how to use a condom (this guy cracks me up):

If you are using condoms, just make sure you:

Check the packaging including for damage, and the use-by date.
Don’t use teeth or fingernails to open the packet. Condoms don’t like sharp objects.
Don’t unroll it all the way before you use it – check to see which way it rolls, pinch the tip and roll it onto the erect penis, all the way to the base of the penis. If you get it on the wrong way, chuck that one out and start again.
Squeeze air out at the tip.
Leave a gap so that sperm has somewhere to go after your partner comes (ejaculates).
Check to make sure there are no defects in the condoms (like holes, brittleness, stickiness, discolouration) and get a new one if it’s been damaged.

are all lubed up as sex with condoms can be downright uncomfortable if you are not slippery and wet.
Don’t use oil-based lubes, as these compromise the integrity of latex condoms. Use water-based lubricant instead.
Begin to use it before intercourse starts – pre-cum still contains sperm which can cause pregnancy.
Use the condom all the way to the end of intercourse (don’t have unprotected sex after you take the condom off)
Hold the base of the condom and promptly remove it after sex. Check for holes
Don’t reuse it – put it in the bin wrapped in tissue.

Image by Reproductive Health Supplies Coalition

The Pill

The oral contraceptive pill is widely used and ubiquitously available in consultation with a registered medical practitioner.

There’s a couple of types: the combined oral contraceptive pill (COCP) and the progesterone-only pill (POP) aka the mini-pill.

COCP

The COCP (or pill) contains synthetic hormones that effectively suppress your brain and ovaries from producing the surges and fluctuations in your own hormones to prevent the maturation and ovulation of egg cells.

There are heaps of brands available these days, and they vary in the type and amount of oestrogen progesterone they contain. The lowest effective dose of oestrogen is recommended, as excess amounts can cause nausea, bloating and breast tenderness.

Breakthrough bleeding (bleeding while taking your active tablets) can however occur with some of the older pills or with lower doses of oestrogen. If this persists or is heavy, it is worth seeing your doctor to investigate other causes for vaginal bleeding.

Additionally, COCPs have been found to cause life-threatening blood clots in some women, especially those with older formulations or higher doses of oestrogen, raising a woman’s baseline risk of blood clots by 3-5 times.

Oestrogen causes a ‘hypercoagulable’ state – in that clots are more likely to occur in the veins, which can travel to the lungs to cause severe chest pain, shortness of breath and sometimes even death. This process also happens in pregnancy and post-partum, where the risk of blood clots is significantly increased (15 and 150-200 times, respectively).

Women who are older, smoke, are overweight, have had previous blood clots themselves or a close family member who has, are not recommended to take the combined oral contraceptive pill, as risks outweigh the benefits.

If you are on the pill and have any periods of inactivity (such as long car drives, plane trips, surgery, you break bones and have to rest), be sure to see a doctor urgently if you experience any pain in your one of your calves, sudden severe chest pain, shortness of breath, headaches or loss of vision.

Some women like the convenience of a single pill per day, taking any missed pills as soon as they remember, with the ability to ‘skip’ or delay periods with continuous dosing of active pills.

It’s considered safe to do this for up to three months at a time (check out this resource here for more information from the Royal Children’s Hospital).

If you take the inactive (or sugar) pills, you will have a withdrawal bleed, but it’s important to remember that this is not the same kind of bleeding as a regular period.

For this reason, doctors might prescribe the pill for control of heavy, painful, irregular periods or pre-menstrual syndrome.

Other side benefits of the pill include control of acne, although some women can actually find they get acne, experience oily skin, hirsutism (hair growth in women where hair doesn’t usually grow) or weight gain with the pill. Other side effects include loss of libido and mood changes.

The pill is effective at preventing 99.7% of pregnancies with regular ‘perfect’ use, however if too many pills are missed, or if you have vomiting, diarrhoea or are taking antibiotics, anti-epileptic medications or herbal remedies (including preparations containing St John’s Wort – commonly used for low mood/symptoms of depression), the effectiveness of the pill is reduced.

Most brands of pill are subsidised by Medicare, meaning they are inexpensive.

You can start taking the pill at any time – if you have your period when you start, you will be protected against pregnancy straight away; if you start at any other time, you will be protected only after taking 7 days of active pills (so make sure you use condoms during this time).

In summary, the pill can be a safe, easy, convenience and inexpensive method of contraception, but make sure you weigh up the benefits with your personal risks when discussing this contraceptive option with your doctor, and read any fine print that comes with the pill you choose.

POP

The POP or mini-pill is similar to the COCP in that it is an oral tablet taken daily, except – as the name suggests – it contains progesterone only, but in smaller amounts. It is similarly cheap, easy to use, although with the mini-pill, there are no breaks: you have to take one each day, within a three hour window, and at least three hours prior to sex.

In itself, that can be a problem for women, who may forget to take the medication or are more frequently sexually active. Sometimes keeping the POP next to your toothbrush or breakfast cereal can prompt you to take one each daily. Of course, you can always set reminders on your phone, as well.

If you miss a mini-pill or take one too late, a second contraceptive is advised for 48 hours.

For this reason, some sources say it’s slightly less effective than the COCP, while the World Health Organization states it’s just as effective – 99.7% if used correctly, and 93% effective if not.

Progesterone thins out the endometrial lining and thickens the cervical mucus, making passage for sperm from the vagina through the cervix and into the uterus far more difficult.

For this reason, there is a range of contraceptives in different formulations that use progesterone only (other than pills/tablets).

Depot Provera is the long-acting progesterone which is an injection (150mg medroxyprogesterone) into muscle (arm or butt) that lasts for three months.

As with the hormonal methods of emergency contraception, the side effects are similar, but this one includes mood changes and weight gain.

It’s 99.8% effective if injections are kept up to date, and can be safely used immediately following pregnancies, including miscarriages, abortions, birth and in breast-feeding women.

If you suspect you are pregnant however, get breast cancer or have abnormal vaginal bleeding (bleeding that is not your period), this option is not recommended.

Chat with your doctor if you have problems with your liver, or take other medications as these can change the way your body processes the progesterone, altering how effective they are. In fact, this is the case with any of the progesterone-only contraceptives (see Depot Provera, Implanon, and Mirena, below).

Implanon

Another option for progesterone is the Implanon, known also as ‘the bar’ or simply, ‘the implant’. The implant is inserted on the first day of your cycle or the next four days to be immediately effective. After local anaesthetic, it’s placed just under the skin on the inner aspect of the upper arm using an introducer needle. Progesterone (etonogestrel) is released slowly over three years, making this a very effective (99.95%) long-acting contraceptive option.

It’s safe to use after a pregnancy, in lactating women, and the benefit of this one is that if you don’t tolerate the side effects, you can have it removed easily. Once the hormone clears from your body, your fertility will return, meaning you can otherwise fall pregnant soon after having the implant removed. See this great infographic website from Family Planning Victoria for more detail.

Okay, so what are the side effects?

All of the progesterone-only contraceptives have similar effects, including breast tenderness, a change in bleeding, making periods lighter, irregular with spotting or absent.

They can worsen acne, cause headaches and weight gain, as well as mood changes and abdominal pain or bloating.

For some women, this precludes their use; for others, they are happy to give it a go. Some women even like the fact they don’t have their period!

Mirena IUD

Mirena is the other kind of intrauterine device (its alternative, the copper IUD, is discussed on under emergency contraception). This IUD is made of thin, flexible plastic, and contains a reservoir of progesterone (levonorgestrel) which releases decrementally over five years.

It’s inserted either in the clinic chair or under a general anaesthetic in operating theatre, using a thin, applicator device that puts the T-shaped device in through your vagina and cervix and into your uterus.

Strings are kept long and protrude out through the cervix to sit in the vagina to ensure correct placement of the device over time, and to also allow for easy removal (the arms of the T push together to form an I shape, and it comes out through the cervix and vagina).

Fertility returns to normal for most women within 12 months.

The effectiveness of Mirena in preventing pregnancy is also very high, above 99%, and can last up to five years, after which time the device needs to be removed and/or replaced.

It has an additional benefit of being very useful in decreasing heavy menstrual bleeding, with clinical trials showing reduction in blood loss between 71-95%.

Many women find they have no period after about 6 months. For women who are debilitated by flooding and heavy periods, this can be an excellent option.

Some women don’t like the idea of a foreign object inside of their uterus, and others report that their partners can feel the strings, though the strings, if left long, encircle the cervix.

The additional risk of this option is infection, so we test all women to exclude this before putting Mirena in.

Like the other progesterone only contraceptive options, Mirena can cause headaches, abdominal pain, changes to your usual bleeding pattern, depressed mood and weight gain.

Less common options for contraception include:

Nuvaring

A thin, flexible ring containing oestrogen and progesterone that is inserted into the vagina for three weeks at a time, then removed for one week then replaced. 93-99.7% effective.

Don’t use this if you smoke. In addition to similar undesirable effects with other hormonal birth control (acne, headaches, depression, weight gain, abdominal pain, breast tenderness), can cause discomfort, irritation and infection. Like COCP, the risk of blood clots also applies.

Read the manufactuer’s website, available from https://www.nuvaring.com and chat with your doctor if you’d like to try this option.

Female condoms

Uncommon, but available from pharmacies.

Works much the same as a male condom, in that it is single use, but inserted instead into the vagina.

Also useful in preventing sexually transmitted infections. 79-95% effective. I looked here for more info.

Diaphragm

A reusable, flexible soft silicone cap that is inserted into the vagina and sits over the cervix.

Must be used along with some dedicated lube prior to sex and left in place for at least 6 hours afterwards. 82-86% effective.

Check out here, here, and/or here for more info.

REFERENCE LIST

Allen, K. (2012). Contraception: Common issues and practical suggestions. Australian Family Physician: Reproductive health edition, 41(10): pp770-772. Accessed from https://www.racgp.org.au/afp/2012/october/contraception/ on 26 May 2021.

Family Planning NSW (n.d.) Contraceptive Diaphragm. Accessed from https://www.fpnsw.org.au/factsheets/individuals/contraception/contraceptive-diaphragm on 19 June 2021.

Family Planning NSW (n.d.) Fact Sheet: The Combined Oral Contraceptive Pill. Accessed from https://www.fpnsw.org.au/sites/default/files/assets/combined_oral_contraceptive_pill.pdf on 26 May 2021.

GLYDE Health (2021). Femidom Condoms for Her. Accessed from https://glydehealth.com/products/female-condoms/ on 26 May 2021.

Government of Western Australia, Department of Health (undated). Get the Facts: female condoms. Accessed from https://www.getthefacts.health.wa.gov.au/condoms-contraception/types-of-contraception/female-condoms on 26 May 2021.

Jones, E.E. (1995). Androgenic effects of oral contraceptives: implications for patient compliance. American Journal of Medicine 98(1A):116S-119S. Accessed from https://pubmed.ncbi.nlm.nih.gov/7825631/ on 26 May 2021.

Marie Stopes Australia (2018). Diaphragm. Accessed from https://www.contraception.org.au/methods/diaphragm/ on 19 June 2021.

Merk & Co. (2020). NuvaRing (etonogestrel/ethinyl estradiol vaginal ring). Accessed from https://www.nuvaring.com on 13 June 2021.

NPS MedicineWise (2020). Consumer medicine information: NuvaRing (ethinylestradiol; etonogestrel) (Full PI). Accessed from https://www.nps.org.au/medicine-finder/nuva-ring-controlled-release-vaginal-contraceptive-ring#full-pi on 18 June 2021.

NPS MedicineWise (2021). Consumer medicine information: Implanon NXT (etonogesterol) (Full PI). Accessed from https://www.nps.org.au/medicine-finder/implanon-nxt-implant#full-pi on 18 June 2021.

NPS MedicineWise (2021). Consumer medicine information: Mirena (levonorgesterel) (Full PI). Accessed from https://www.nps.org.au/medicine-finder/mirena-intrauterine-device on 18 June 2021.

Planned Parenthood Federation of America () How effective are condoms? Accessed from https://www.plannedparenthood.org/learn/birth-control/condom/how-effective-are-condoms on 21 May 2021.

Sanders, S.A. Yarber, W.L., Kaufman E.L., Crosby, R.A., Graham, C.A., Milhausen, R.R. (2012). Condom use errors and problems: a global view. Sexual Health. Accessed from https://www.publish.csiro.au/sh/Fulltext/SH11095 on 26 May 2021.

Shine SA (n.d) Diaphragms. Accessed from https://shinesa.org.au/health-information/contraception/diaphragms/ on 19 June 2021.

Stewart, M. & Black, K. (2015). Choosing a combined oral contraceptive pill. Australian Prescriber. NPS MedicineWise. Accessed from https://www.nps.org.au/australian-prescriber/articles/choosing-a-combined-oral-contraceptive-pill#non-contraceptive-benefits on 26 May 2021.

The Royal Children’s Hospital Gynaecology Department (2018). Oral contraceptives – skipping periods when taking the Pill. Accessed from https://www.rch.org.au/kidsinfo/fact_sheets/Oral_Contraceptives_-_Skipping_periods_when_taking_the_Pill/ on 26 May 2021.

True Relationships & Reproductive Health (2019). Combined oral contraceptive pill. Accessed from https://www.true.org.au/health-information/contraception/combined-oral-contraceptive-pill-cocp on 26 May 2021.

Weisberg, E. (1999). Progestogen-only methods of contraception. NPS MedicineWise. Accessed from https://www.nps.org.au/australian-prescriber/articles/progestogen-only-methods-of-contraception on 18 June 2021.

WHO (2020). Family planning/contraception methods. Accessed from https://www.who.int/en/news-room/fact-sheets/detail/family-planning-contraception on 26 May 2021.

World Health Organization Department of Reproductive Health and Research & Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP) (2018). Family Planning: A Global Handbook for Providers). Baltimore & Geneva. Accessed from https://apps.who.int/iris/bitstream/handle/10665/260156/9780999203705-eng.pdf?sequence=1 on 26 May 2021.