A guide to contraceptive methods

Not everyone is ready or wants to start a family. In this article, consultant GP specialising in women’s health Dr Wendy Knoops describes the different options for contraception, ranging from accessories, medications, and surgeries.

When considering contraceptives, patients can identify and compare different methods based on their lifestyle, preferences, desire for future pregnancies and whether hormonal methods are safe and suitable.

The types of contraception

Fertility awareness

Using fertility awareness relies on observing and tracking natural fertility signs to prevent or achieve pregnancy. It involves monitoring changes in body temperature, cervical mucus, and menstrual cycle patterns to determine fertile and infertile periods. By avoiding intercourse during the fertile window or using other methods like abstinence, couples can either avoid pregnancy or try to conceive. It is a hormone-free approach and requires awareness, commitment, and consistency in tracking fertility signs. It is often used by couples who prefer a natural and non-invasive method of family planning. Effectiveness can be quite variable due to the need for compliance, accurate timing and individual variation in a menstrual cycle.

Barrier methods

Condoms are the most easily accessible barrier method available. In some areas in the UK they are provided for free, and they are easily available to purchase. Condoms are sheathes of latex, though there are latex-free options for people with latex allergies. They act as a physical barrier to prevent semen from entering the cervix into the womb. The most common kind of condom is for a penis, but there are condoms that can be inserted into the vagina as well. Female condoms can be a bit more expensive and more difficult to find but are also freely available in sexual health clinics. Although condoms can be effective at preventing a pregnancy, their reliability can vary between users and the failure rate can be much higher than expected. Incorrect usage and breakage of condoms is quite common, reducing the efficacy significantly.

One additional advantage of condoms is that because they block any fluid transfer in addition to semen, they are one of the best methods to prevent sexually transmitted infections (STIs), which other options are not able to do.

There are also diaphragms available as barrier methods. The diaphragm is a barrier method of contraception that is inserted into the vagina to cover the cervix and prevent sperm from entering the womb. Made of soft, flexible material, it is typically used with spermicide to increase its effectiveness. There are different types of diaphragms, with some requiring fitting by a healthcare provider to ensure proper size and placement, and others that are more generic that can be purchased without the need for a healthcare provider. It is used before intercourse and needs to be left in place for several hours afterwards to ensure maximum effectiveness. Its reliability and efficacy can vary between users, and it requires timing and compliance to be used correctly. Despite it being a barrier method, it does not protect against STIs.

Hormonal methods

One of the most popular options is hormonal contraceptives. These can either be combined methods containing oestrogen and progestogen or progestogen only. The range of options include pills, patches, vaginal rings, implants, intrauterine devices and injections. For some methods, they work by inhibiting ovulation, thus providing a very reliable contraceptive method. Some also thicken cervical mucus to prevent sperm from entering the womb and thinning the lining of the womb to prevent pregnancy.

Combined methods containing both oestrogen and progestogen, which can make periods lighter and less painful. They require regular compliance as missing a dose can result in failure of the method. Options include:

The pill: A daily oral contraceptive taken to prevent ovulation with some requiring a short 4-day break every 28 days. It can be taken continuously or with a short break to provide a withdrawal bleed.
The patch: A small adhesive patch worn on the skin releasing hormones over a week, requiring a weekly change for three weeks, then followed by a week off.
The vaginal ring: A flexible ring inserted into the vagina, releasing hormones for three weeks, followed by a week off.

Progestogen-only methods can be highly effective when not relying on user compliance. These methods can make periods lighter and less painful but also can lead to irregular bleeding in some women. In some cases, they stop menstruation altogether, which is very useful for women with heavy periods. They are very effective methods of contraception and have the option of long-term use without needing much compliance. Options include:

The ‘mini’ pill: A daily oral contraceptive that contains only progestogen. For most mini pills there are no breaks although there are newer versions that offer a 4-day break.
The contraceptive injection: An injection that is given every three months. The main consideration for those planning a pregnancy in the future is that it can delay the return of natural fertility for several months after stopping.
The contraceptive implant: A small rod inserted under the skin of the arm, releasing progestogen for up to three years. This is a highly effective method, and the failure rate is the lowest compared with all other female options with over 99% efficacy. The rod needs to be inserted and removed by a trained healthcare provider, but once removed natural fertility returns very quickly.
The intrauterine hormonal system: A small T-shaped device placed in the uterus, releasing progestogen for several years. There are different strengths and sizes available to suit each individual, providing contraception for 3-8 years depending on which device is inserted. This method requires a trained healthcare provider to insert and remove the device.

Copper intrauterine device

Not everyone is suitable for hormonal contraceptives, such as those with a history of high blood pressure, migraines with aura, blood clotting and hormonal cancers. For some, hormonal methods have side effects, such as mood changes, breast pain, nausea, and headaches. A highly effective method for those wanting to avoid hormones is the copper intrauterine device (IUD). The copper is toxic to sperm and the device can last 5-10 years depending on the type used. There are different sizes to suit each individual and insertion requires a trained healthcare provider. As it has no hormones, the menstrual cycles are not affected apart from that for some women the bleeding can be heavier and more painful.

Surgical

For those looking at permanent options, there are surgical procedures that both men and women can explore. For women, there is tubal ligation, also known as having the ‘tubes tied’. It involves blocking or cutting the fallopian tubes to prevent a released egg from travelling to the womb. As it is a structural contraceptive method, periods still occur and the ovaries still produce their own natural oestrogen and progestogen. This procedure involves surgery and requires a trained gynaecologist to operate in a hospital setting.

For men, there is vasectomy, which involves the cutting and blockage of the vas deferens, the two tubes through which sperm travels from the testicles to the penis. Once the vas deferens are cut, the ejaculatory ability is unaffected, but the semen no longer is comprised of sperm and just consists of the seminal fluid. This method is highly effective with a very low failure rate but requires follow-up semen samples to confirm this. Although a surgical procedure, it is usually done in clinics by a trained healthcare provider using local anaesthetic only. It is a very quick procedure with minimal recovery time, providing an effective long-term option.

To further explore the different contraceptive methods in more detail, please visit this link.