Birth Control Hormonal Options:Pills, Shots, and Implants

omen were preventing pregnancy long before there were any books about it—in fact, even before there was paper for printing the books. The first prescription for a contraceptive was written on papyrus around 1550 B.C. It seems to have called for crocodile dung to be inserted into the vagina, as the ancient Egyptians preferred. For ancient Arabians, elephant dung mixed with honey was the method of choice. And women in Northern Canada drank a potion of dried beaver testicles mixed with alcohol to avoid pregnancy.

Fortunately, technology has advanced to a point where we no longer have to rely on such methods of contraception. Modern science allows us to convert natural substances, such as the Mexican yam, into remarkably simple delivery systems, like tablets, subdermal implants, and shots.

Hormonal birth control methods— including oral contraceptives (the Pill), the Norplant implant, and Depo­Provera Contraceptive Injection—have several things in common. They are all highly effective and safe for most women; they all reduce cramping and pain related to the menstrual cycle; and they all require a doctor's prescription. Unfortunately, these forms of birth control offer little protection from sexually transmitted diseases; and all may be accompanied by health risks and side effects.

How Hormonal Methods Work

Pills, implants, and injections all have one goal: to prevent your reproductive system from producing a mature egg. They do this by tricking the system into skipping a key step in the interlocking cycle of hormone production that triggers the egg's release from the ovary. The deception works like this:

Under ordinary circumstances, the brain's hypothalamus produces GnRH (gonadotropin­releasing hormone). This prompts the pituitary gland to release FSH (follicle stimulating hormone) which travels to the ovaries through the bloodstream and causes a follicle to grow. The development of the follicle produces estrogen, which after about 10 days reaches high enough levels to trip off a surge of LH (luteinizing hormone) from the pituitary gland. The ovarian follicle releases a mature egg into the fallopian tube about 24 hours after this surge of LH, and the empty follicle becomes known as the corpus luteum. The cells of the corpus luteum produce progesterone and estrogen, which together stimulate the uterine lining to thicken with blood in preparation for nurturing a fertilized egg. Once the corpus luteum wanes and the lining is left with no hormonal support, it sloughs off during your monthly period. The low levels of estrogen and progesterone also signal the hypothalamus to start the process over again.

Since oral contraceptives (OCs) provide a steady level of both progestin (a substitute for progesterone) and estrogen every day, and Norplant implants and Depo­Provera provide steady daily levels of progestin, there is no signal to the hypothalamus to release GnRH and therefore no signal to the pituitary gland to produce FSH and LH. Because FSH stimulates the ovaries to grow egg follicles, and LH triggers ovulation, their absence causes the ovary to be relatively dormant, and no egg is produced to a point where it could be released. Hormonal contraception locks the system into the same late phase of the cycle on a continuous basis, perpetually skipping the all­important release of GnRH.

HOW HORMONAL METHODS SHORT-CIRCUIT THE REPRODUCTIVE CYCLE

Hormonal contraceptives work by damping down the two key hormones that trigger ovulation. Follicle stimulating hormone (FSH), the substance that coaxes an egg towards maturity, is the first to be suppressed. Luteinizing hormone (LH), which ordinarily triggers release of the egg at mid-cycle, is also held down. Production of both these substances usually starts when the body senses a shortage of two other hormones: progesterone and estrogen, both produced in the ovaries. Hormonal contraceptives supply just enough of these substances to prevent start-up of the FSH/LH production cycle. Constant levels of estrogen and progesterone thus produce constant levels of FSH and LH, and the eggs remain dormant.

Suppression of ovulation is the main mode by which OCs and Depo­Provera prevent pregnancy; the implant system causes ovulation suppression about 50 percent of the time. However, throughout each pill cycle, and continuously with Norplant implants and Depo­Provera, the mucous covering the cervix—the site where sperm enters the uterus—stays thick and sticky, making it very difficult for sperm to get through. This gooey impediment also acts on the sperm cell itself. It prevents fertilization by interfering with chemical changes inside the sperm that allow it to penetrate an egg's outer coating.

Even if ovulation and fertilization do take place, hormonal methods provide another measure of protection: changes to the uterine lining. Normally, estrogen initiates the thickening of the lining of the uterus in the first part of the cycle, while progesterone kicks in later to help the lining mature. Since both hormones are present throughout the pill cycle, and progestin is supplied continuously by implants and the shot, the usual hormonal variations are masked and the lining rarely has a chance to develop enough to nurture a fertilized egg.

All the hormonal methods currently available to us offer many benefits, including protection from cancer. However, they aren't 100 percent effective, and they aren't right for all women. To correct this, scientists are busy developing new forms of hormonal contraception which may be easier to use and may suit more women. These methods include biodegradable implants, pellets the size of a grain of rice, and a new product called the vaginal ring. Like a diaphragm, this device is removable. But unlike barrier contraceptives, it releases steady levels of progestins to prevent pregnancy.

Even without these new approaches, the array of choices at your disposal is varied and wide. Before you decide on a method take time to weigh the benefits and risks of all the forms of hormonal contraception available today. The following overview provides the basic information you'll need, but be sure to discuss any questions with your physician. Together you can find the approach that's optimal for you personally.

Oral Contraceptives

Birth control pills have been popular since the 1960s, and today they are relied upon by more than half of all women using a reversible method of birth control. Over the years, a tremendous amount of research has been done on their effects, but despite the large body of knowledge available, scientists are still at work investigating such things as the association between OCs and breast cancer.

Even if you think you're well informed about oral contraceptives, take this quick true/false quiz to determine your “Pill I.Q.”:

• The Pill works by destroying the egg once it is released from the ovary.
• Taking the Pill too long makes it difficult for most women to conceive; it may even cause them to become sterile.
• A woman should take a short break from the Pill after she has used it for five years.
• Women over 35 years old should not take the Pill.
• Taking the Pill can lead to many types of cancer, including ovarian and endometrial cancer.

If you answered false to all these statements, you know more about the Pill than a great many people. A recent Gallup poll of over 1,000 American women aged 18 to 44 found that knowledge is sorely lacking about this widespread method of birth control. For example, one­quarter of the survey's respondents believed that the Pill works by killing the egg, when in fact it inhibits egg production altogether.

Taking OCs for many years poses no increased risk of infertility, as was believed by 45 percent of the respondents. Experts say women don't need to take a break from the Pill, even after using it for long periods of time.

Forty­three percent of those interviewed said that women over age 35 shouldn't take OCs. However, the truth is that healthy nonsmoking women can use OCs all the way through menopause without any detriment to health.

More importantly, very few women interviewed for this poll knew that the Pill can actually protect women from certain health problems, including some types of cancer. Although it is clearly stated on the Pill package insert, less than 20 percent of women polled knew that the Pill helps reduce the incidence of ovarian and endometrial cancer, ovarian cysts, and benign cysts of the breast.

The Pill is not right for all women because, despite its beneficial effects, it is also associated with some risks. Doctors usually advise women likely to suffer from heart attacks, strokes, or blood clots—especially those who smoke—to choose some other type of contraception. Several other conditions, such as hypertension, diabetes, or sickle cell disease, also make Pill­taking risky.

The following information should help you improve your “Pill I.Q.”

Your OC Options

Birth control pills come in packs of either 21 “active” pills (containing hormones), or packs of 28 pills, 21 of which are active and seven of which are inactive placebos. The placebo pills are simply a way of staying in the habit of taking a daily pill, even while having your period.

Either package, 21 days or 28 days, can be “monophasic” or “triphasic.” Monophasic pills provide the same dosage level of hormones all through the active cycle, whereas triphasic pills give different dosage levels during each week of active pills. Triphasics were designed to more closely follow a woman's natural hormonal pattern. However, most experts say the fluctuations don't really matter and may even cause extra problems, such as increased “breakthrough” bleeding (sporadic menstruation) while on the Pill, or an increase in Pill-related headaches.

Birth control pills are either called “combined” OCs or “progestin­only” OCs. Combined pills are a combination of the hormones estrogen and progesterone. Progestin­only pills, also called minipills, lack the estrogen component. Since women shouldn't use estrogen­containing products when they are breastfeeding, minipills are often prescribed for women who want protection from pregnancy six weeks after they give birth. Minipills also have lower doses of progestin than combination forms, making them a good choice for women worried about metabolic effects of the hormones (but a bad choice for women who want highly effective birth control). They also require a woman to take them on a rigidly regular schedule.

How Effective Is the Pill?

Given all the ways the Pill discourages fertilization it's hard to believe that anyone can get pregnant while using it. And in fact, the Pill does have an effectiveness rate of over 99 percent when used correctly, (taking an active tablet every day during the 21­day cycle). However, because women do forget to take a pill now and then, actual effectiveness in real­world use is about 97 percent.

That may sound pretty good, but remember that it does fall short of total certainty. For example, even assuming the Pill is 99.5 percent effective, 84,000 of the 16.8 million women currently using OCs will have an unintended pregnancy, even if they take their pills correctly every day! If you are concerned about accidental pregnancy while using OCs, you should use a backup method—like a condom or spermicide—each time you have sex. In addition to allaying your fears about getting pregnant, a latex condom, unlike the Pill, will help protect you from the viral types of sexually transmitted disease.

The Benefits and Risks

OCs are among the most thoroughly studied drugs in the world. The vast body of data collected on them indicates that although they do have certain side effects, few women are likely to experience them. Moreover, most of the information on side effects was collected from studies of higher dose pills than those generally in use today. And research done in the Pill's early years involved women who had not been screened to see if they were good candidates. Today, women with a personal or family history of heart disease or other illnesses linked to the Pill are usually steered towards another method of birth control. If you are healthy, you don't smoke more than 15 cigarettes a day, and no one in your family has suffered from cancer, a heart attack, or very high cholesterol, you may never experience any of the more serious side effects.

The Pill can produce both “nuisance” side effects and more serious health problems. Included among the more serious potential effects are increased risk of cervical and liver cancer (and possibly breast cancer—studies so far are inconclusive), heart and blood vessel disorders (clots and high cholesterol), high blood pressure, increased blood sugar levels, complications with the liver and gallbladder, cervical changes (increasing your risk for sexually transmitted diseases), eye problems, and delays in fertility once pills are discontinued. Some women at risk for these complications can continue taking OCs if they use them cautiously. Your doctor should be able to help you determine whether or not you should avoid the Pill.

Cancer: Women who have used OCs sometime in their lives are less likely to develop cancer by age 55 than women who have never taken the Pill. Oral contraceptives really do protect against certain kinds of cancer. If you use OCs for at least a year, your risk of developing endometrial cancer diminishes by 50 percent and it drops even more after three years of Pill use. The protection lasts up to 15 years after you stop using OCs.

Ovarian cancer, the most lethal of all female reproductive tract cancers, is also 40 percent less likely to develop in a woman who has used OCs. Even if you use OCs for as little as three months, you get some protection, but to get the full effect you need to take them for 5 to 10 years. If you use them for 10 years, your risk is reduced by 80 percent. The protection lasts for at least 10 to 15 years after discontinuation.

Endometrial and ovarian cancer are not the most common female cancers. Still, an estimated 2,000 cases of endometrial cancer and 1,700 cases of ovarian cancer were averted by Pill use in the 1980s.

OCs do not protect women from cervical cancer. In fact, the opposite may be true. Women who take the Pill for over a year appear to run an increased risk of developing this disease, the risk doubles when the medication is taken for 10 years. However, the most important risk factors for cervical cancer are not OCs, but rather the number of sexual partners a woman has had and how old she was when she first had sex. Exposure to human papillomavirus (HPV) and smoking also increase a woman's risk, while the use of barrier contraceptives, such as a diaphragm, condoms or spermicides protects against cervical cancer. It is difficult to determine the impact of these factors in women with cervical cancer who also used OCs, so research results have not been definitive. One study conducted by the Centers for Disease Control and Prevention (CDC) showed that women who used OCs didn't get cervical cancer more often than non­users. Instead, the higher rate of cancer diagnosed among these women was simply due to more careful screening, including more frequent Pap smears.

One woman in 9 will develop breast cancer during her lifetime, so it's not surprising that breast cancer is the main concern of anyone considering use of OCs. Unfortunately, despite a large body of scientific evidence showing no association between the two, a few studies have seemed to uncover an increased risk of breast cancer among those using OCs. Researchers aren't sure if these studies are important or if they are merely aberrations. It will probably take a decade or more before they reach a definitive conclusion. Many experts do agree that OC use is not associated with breast cancer after age 45. Some younger women, however, may be at higher risk. Several studies have shown that women who use OCs early in life, use them for longer than four years, and/or don't have a full term pregnancy early in life have a slightly increased risk for breast cancer. (However, other research concludes the opposite.)

OC use has been implicated in a rare form of liver cancer known as hepatocellular carcinoma. However, since so few people ever develop this cancer, it has been difficult for researchers to determine with accuracy whether OCs were actually the cause. The largest study to include data about hepatocellular carcinoma found no association with OC use. In addition, death rates from liver cancer in the United States haven't changed since the introduction of OCs to the marketplace in the 1960s.

Despite a suggestion that OC use might lead to skin cancer, follow­up studies indicate no difference in the risk for Pill users versus nonusers. There is also no proven relationship between OCs and kidney cancer, colon cancer, gallbladder cancer, or pituitary tumors.

Heart and blood vessel disorders: Although concerns about cancer are usually foremost in the minds of women using OCs, the Pill's effects on blood chemistry are actually a greater cause for worry. Both the hormones in combined OCs are responsible for these problems, but in different ways.

The progestin component of OCs can alter the level of lipids (such as cholesterol) in the blood. Although estrogen works against this effect by increasing beneficial high­density lipoproteins (HDL) and lowering harmful low­density lipoproteins (LDL), progestin opposes the estrogen and does the opposite. Because high levels of LDL and depressed levels of HDL can cause fatty plaque to build up in the arteries, progestins have been implicated as a risk factor for coronary heart disease.

The estrogen component has been linked to a different problem: an increase in abnormal blood clotting, which can block circulation. A blood clot can appear in any blood vessel, but it is especially serious if it occurs in the brain, heart, or lungs.

Clots or blockages to blood flow can lead to serious and sometimes fatal complications that are usually associated with the following risk factors:

• Family history of heart attack or diabetes
• Previous heart or blood vessel disease
• Smoking
• High blood pressure
• Overweight
• Inactivity (either from too little exercise or from being immobilized)

If you have any of these risk factors, you should ask your physician whether the benefits from taking the Pill outweigh the possible dangers. Doctors and private clinics usually make this decision on a case-by-case basis. Public clinics may have stricter rules against giving OCs to women with certain risk factors.

Here is a description of the symptoms you might experience if you are suffering from a blood clot or blockage, and the technical name your doctor might use to describe it. If you think you have one of these problems, seek medical attention as soon as possible.

• Headache, impairment of the intellect, visual problems, weakness or numbness— Cerebral infarction (stroke)
• Chest pain, difficulty breathing, left arm and shoulder pain, weakness— Myocardial infarction (heart attack)
• Calf pain or swelling, heat or redness in the thigh, heat or tenderness in the lower leg, pain— Thrombophlebitis
• Chest pain, cough, shortness of breath— Pulmonary embolism
• Abdominal pain, vomiting, weakness— Mesenteric vein thrombosis
• Headache, loss of vision— Retinal vein thrombosis
• Cramps, lower abdominal pain— Pelvic vein thrombosis

High Blood Pressure: Although in itself not a life threatening condition, Pill­related high blood pressure—experienced by up to 5 percent of women taking high­dose pills—can lead to heart disease and stroke. If your blood pressure is over 140/90, you should stop taking OCs until it is under control. All women using the Pill should have their blood pressure checked once a year; for women with a history of blood pressure problems, a check once every six months is probably in order.

Increased Blood Sugar Levels: Estrogen and progestin not only can affect blood clotting and blood lipids, they can also raise blood sugar levels. Most experts believe these changes are so minimal, they have no clinical significance. For women with diabetes, however, the situation isn't so straightforward. Some doctors believe that diabetic women with no other risk factors can use OCs with minimal trouble, but others believe prescribing OCs to diabetics exposes them to unnecessary risks.

Liver and gallbladder complications: OCs can cause jaundice—a liver condition that makes the skin and eyes look yellow—but only 1 in 10,000 Pill users experience Pill­related jaundice. OCs can also cause another rare liver condition known as hepatocellular adenoma. The risk of developing this condition is about 3 or 4 per 100,000 Pill users. Liver cancer is another rare complication. Gallbladder disease, which is fairly common among users—and non­users—of the Pill, is not life threatening but could require surgery.

Cervical changes: The thickness and strength of the cervical lining varies with the ebb and flow of reproductive hormones; and OCs can lead to an increase in the area of thin, vulnerable cervical tissue susceptible to sexually transmitted diseases (STDs). Most doctors recommend you use condoms for STD prevention while taking the Pill to prevent pregnancy, especially if you have more than one sexual partner and if you are less than 25 years old.

Eye problems: Use of older, high­dose OCs occasionally caused an inflammation of the optic nerve, resulting in blurred or double vision, swelling, pain, or even loss of sight. This almost never happens with today's OCs. However, any loss of vision warrants an immediate discontinuation of the Pill and a visit to an ophthalmologist or neurologist. You should also stop taking the Pill if a vision problem accompanies a migraine headache.

Returning to fertility: For most women, fertility comes back quickly after discontinuing OCs. However, 1 percent to 2 percent experience some delay in the return of normal reproductive cycles. In rare instances, hormones can stay suppressed for months or even years, though for the majority, menstrual cycles normalize within three months. Cycle suppression is more likely to cause infertility in older women, so if having a child is a high priority, you might consider switching to another reliable contraceptive method as you approach 30.

Nuisance Side Effects

Some women experience minor “nuisance” side effects while using the Pill. Of course, depending on your level of discomfort, a nuisance can become serious enough to warrant switching to a different OC or discontinuing the Pill altogether. Additionally, some minor side effects could actually be masking a condition that needs medical attention. Never hesitate to mention a side effect to your physician. Among the minor side effects the Pill sometimes produces are acne, breakthrough bleeding or spotting, breast tenderness, depression, headaches, nausea and weight gain.

Acne: Pill users may notice an improvement, a worsening, or no change in their acne. In some women, the progestin component of the Pill improves the acne; in others it works like the male sex hormone, androgen, and makes it worse. (Women produce androgen in small amounts.) Dietary, allergic, hygienic, or familial factors can also increase acne. A bad case could be a sign of an ovarian or adrenal tumor, although chances of this are minimal.

You have several options if you break out with acne while on the Pill. Recently, new lower dose pills containing so­called “new progestins,” were introduced to the American market. These pills have been used in Europe and other parts of the world for over 30 years with great success. Although many claims are made about them, so far their only real benefit appears to be their lower androgenic properties. Ask your doctor about these pills containing progestins called norgestimate (Ortho­Cyclen, Ortho­Tricyclen) and desogestrel (Desogen, Ortho­Cept). A third new progestin called gestodene, which could actually be the best of the three because it can be used at the lowest dose, could become available in the U.S. sometime in the future.

The new pills are more expensive than the older high-dose pills, so you'll have to decide if improving your acne is worth the added expense. You might choose to switch to another of the older pills instead. You can also consider taking antibiotics, changing your diet, or using a special cleanser.

Breakthrough bleeding or spotting: Intermittent minor menstrual bleeding could mean that your pill isn't strong enough, or it could signal a pelvic infection, endometriosis, or ectopic pregnancy. Once your doctor has ruled out these more serious possibilities, he or she will either switch you to a different pill (probably one with a higher dose of progestin or one of the new progestin pills) or counsel you to try to tolerate the bleeding and spotting for a little while longer, especially if you just started on the Pill. Breakthrough bleeding and spotting diminish rapidly over the first four months of pill use.

Most physicians do not recommend stopping the Pill because of this side effect. If you have any doubts, however, call your doctor.

Breast tenderness: If your breasts hurt, your doctor will first rule out pregnancy and breast cancer. He or she may then prescribe a different, lower dose pill.

You may also want to try wearing a different bra with better support. Also try to avoid vigorous exercise when you have the most discomfort.

Depression: It's difficult to prove a direct link between depression and the Pill. A woman who's chosen the Pill may still have strong moral or medical concerns about it. Starting on the Pill may also coincide with increased sexual activity, which may cause deep psychological conflicts for the user. This inner turmoil can easily seem like depression. It is important to decide whether there could be other reasons for your feelings, and to note whether your depression started or became worse when you began taking the Pill.

If you rule out depression from sources other than the Pill, there are several Pill­related remedies your doctor can try. Most likely the culprit is the progestin in the Pill, so your physician might try prescribing a pill with less of that hormone. Pill­related depression can be the result of fluid retention or a lack of vitamin B ₆, among other causes. Talk with your doctor about the best plan of action. If your depression seems severe, he or she may suggest you discontinue the Pill and talk with a specialist.

Headaches: Although OCs sometimes initiate headaches or make them more severe, headaches can also be a warning of impending strokes or other circulatory disorders. Pay close attention to headaches that are different or more severe than those you had before starting on the Pill.

Estrogen seems to be the culprit in Pill­related headaches, so you might find relief by changing to a lower dose pill, or switching to a progestin­only method like Norplant implants or Depo­Provera. If you usually get headaches only during the week you're not taking pills—the placebo week—you might have what's called an estrogen withdrawal headache. To determine whether this is the case, consider using an estrogen supplement. For example, during your withdrawal week, you can try wearing a transdermal patch that releases estrogen through the skin.

Another approach to estrogen withdrawal headaches is simply to put off withdrawal from the Pill. Essentially, you postpone the headache by extending the amount of time you take active pills. A recent year­long study of 300 women showed that those who opted for an extended regimen—taking active pills for 9 weeks instead of 3 and then taking a withdrawal week—had fewer headaches. Continuing the active pills for the extra time caused no serious side effects and no decline in effectiveness.

It may seem unnatural to take pills for longer than the standard 3 weeks, but remember that the entire pill cycle is essentially unnatural. As one family planning expert puts it, “The day was made by God, the week was made by man.”

Nausea: Although it could signal pregnancy, early miscarriage, or some nonreproductive disorder, when nausea is related to the Pill, it's the estrogen component that's at fault. For a new Pill user, nausea usually subsides after the first few cycles or remains a nuisance only on the first day of each new cycle.

In addition to switching to a pill with a lower estrogen dose or to a progestin­only method, another possible remedy is taking your pill after a meal. Swallowing a pill before going to sleep has also helped some women.

If the nausea is so bad that you vomit within 1 hour of taking a pill, take another pill from an extra pack. Also, if you missed a pill and are trying to catch up, take the next 2 pills at least 12 hours apart. (For more information see the nearby box on “What To Do When You Miss a Pill.”)

Weight gain: Some doctors refuse to acknowledge that the Pill can cause excessive weight gain. Although your doctor might switch you to a different pill, it could be because you believe it will help rather than because he or she thinks it will.

Weight gain that occurs after you start using the Pill may be caused by fluid retention or estrogen­induced fat deposits in the thighs, hips, and breasts. It may also be the result of reduced physical activity or increased intake of food. (The androgenic effects from the progestins in the Pill can cause an increase in appetite.)

Switching to lower dose pills or to pills with less progestin content can help, but increasing exercise and reducing caloric intake is often the best solution.

Emergency contraception

Contraception is usually thought of as a measure to be taken in advance of or during sex. But even though many women don't realize it, something still can be done after the fact —after unprotected sex; after a condom breaks; after a diaphragm, cap, or sponge becomes dislodged; or after a rape. Called by several names—such as the morning­after pill, postcoital contraception, emergency contraception, or interception—the regimen involves ingesting higher­than­normal doses of contraceptive hormones within 72 hours of intercourse, and then ingesting even more of the same hormones 12 hours later.

The drug companies that sell OCs don't have approval from the Food and Drug Administration to market their pills for emergency contraception, mainly because they haven't applied for it. However, physicians are allowed to prescribe an approved drug for any purpose they deem reasonable; so normal birth control pills—maybe ones similar to those in your drawer or purse—have been used after the fact since the early 1980s to prevent possible pregnancies.

There are several different postcoital treatment options available in the United States. The regimen of choice involves the use of an OC called Ovral, a high­dose pill containing the progestin norgestrel.

Here's how the regimen works: Two Ovral tablets are taken within 72 hours of unprotected sex; then 2 more Ovral tablets are taken 12 hours after the first dose. Because this much hormone can upset your system, always talk with your doctor before attempting emergency contraception of this type.

Depending on where you are in your menstrual cycle, postcoital pills work by either stopping release of an egg from the ovary, disrupting fertilization by the sperm, or preventing a fertilized egg from implanting in the lining of the uterus.

NORPLANT: THE “NO HASSLE” APPROACH TO HORMONAL CONTRACEPTION

The Norplant system requires just one trip to the doctor every 5 years—and nothing else! There's no daily pill to remember and nothing to fuss with before sex. The only major drawback to the system is the insertion procedure. Because the 6 levonorgestrel-filled capsules that make up the system must be placed under the skin, you can expect tenderness and swelling of your upper inner arm for a couple of days while the insertion site heals.

The most significant side effect is severe nausea, which affects about one­third of women using this regimen. However, this should stop a day or so after treatment. If the nausea is so severe that you have to vomit within an hour of taking the dose, you may need to take extra pills. You can also get anti­nausea medication from your doctor. Other side effects you might experience include headache, breast tenderness, dizziness, and fluid retention.

You should have your period in 2 or 3 weeks. If it hasn't started in 3 weeks, consider taking a pregnancy test. And don't forget to watch out for the Pill warning signs (turn to the “See Your Doctor...” box, page 267).

There are several other brands of pills containing norgestrel, including Lo/Ovral, Nordette, Levlen, Triphasil, and Tri­Levlen. If you are currently taking any of these pills, you can use them in an emergency, but you'll have to take twice the amount because they aren't as strong as Ovral. This means you will need to take four tablets within 72 hours, and then another four tablets 12 hours later. If you use the triphasic pills (Triphasil or Tri­Levlen), make sure you take only the pills designated for the last week. These are the ones with the right dose. Again, be sure to consult your physician before using OCs in this way.

Other progestin­based brands would probably work the same way, but they haven't been studied, so experts can't reliably make any recommendations.

Reported effectiveness rates for this treatment option vary, but a recent study found that emergency contraception of this type can be up to 75 percent effective, depending on where a woman was in her cycle when she had unprotected sex.

Norplant Implants

Oral contraceptives are the most widespread method of birth control, and they are well liked by most of the women who use them. However, if they were asked to name just one complaint about the Pill, most would probably say that it's hard to remember to take a tablet every day. To combat the problems that can arise from forgetting to take the Pill regularly (or not using a condom every time, or leaving the diaphragm at home...), researchers began searching for birth control methods you don't need to remember.

Scientists at the Population Council in New York City, an international, nonprofit contraceptive research organization, spent more than 20 years and over $20 million developing and introducing Norplant implants. This new system is effective for up to 5 years without replacement. Women around the world have been using the implants since the early 1980s. The Food and Drug Administration approved them for use in the United States at the end of 1990.

What the Implants Do

The Norplant implant system is a set of 6 matchstick sized, hormone­containing capsules made of flexible tubing. The tubing is a blend of silicone and plastic called Silastic. The capsules are inserted by a trained professional just below the skin of a woman's upper inner arm (the part of the arm that lies against the side of the rib cage when the arms are at rest). The doctor uses a device that looks like a syringe (called a “trocar”) to place the capsules in a fan­like shape. Thin women will probably be able to see the cap sules under the skin once they are inserted, but for most others they aren't noticeable.

Starting 24 hours after the capsules are placed under her skin, the user is protected from pregnancy by the progestin called levonorgestrel, which slowly leaks out of the capsules and enters the bloodstream. The implants contain no estrogen. They will continue to release progestin for up to 5 years. Because they are not biodegradable, they must then be removed. Your doctor can insert another set of implants at the same time the old set is removed, if you want to continue using the method.

The implants should be inserted within 7 days of the start of your menstrual cycle, just to make sure you aren't already pregnant. Although there is no evidence that the Norplant system will hurt a developing baby, most experts believe it's best not to expose it to hormones.

The insertion procedure is done on an outpatient basis. Your doctor will give you a local anesthetic to numb the area, then make a small incision. It takes about 15 or 20 minutes to place all 6 capsules. The area will probably be tender, bruised, or slightly swollen for a day or two.

If you want the implants removed—when the five­year effectiveness begins to wear off, you want to get pregnant, or you simply don't like the method—you will again need a minor outpatient surgical procedure. Removal is often more difficult than insertion, sometimes requiring 2 sessions before all 6 capsules are removed. Two visits are necessary when swelling of the surrounding tissue becomes an impediment to the doctor and a discomfort to you.

Removals often present a problem for doctors because your skin tissue forms an envelope around the implants, making them difficult to grab with the tweezer­like instrument often used to take them out. The tissue envelope, which gets thicker and harder to remove as time goes on, must first be disrupted before the capsules inside can be pulled out. Many clinicians can remove a set of six capsules in 30 minutes. Some take longer, while others complete the procedure in as little as 10 minutes.

Twenty­four hours after the capsules have been removed, your protection from pregnancy ends.

Many women and their doctors were dubious about the system's eventual success when it was first introduced in the United States. They wondered why women would want to have these tiny sticks buried beneath their skin. To their surprise, the odd new method became almost an instant hit. In just over 2 years, 750,000 American women have chosen the implant system.

Most of these women received the implants with the help of the Medicaid system or private insurers. Norplant implants do have high up­front costs; the kit itself is about $365, insertion costs can start at $100, and removal costs average $400 to $500. However, depending on where you live, the implants may cost less than or about the same as 5 years' worth of birth control pills.

How Effective Are the Implants?

The Norplant implant system is one of the most effective birth control methods in use today. During the first year after insertion, there is only one pregnancy per 500 users. The system becomes less effective towards the end of its useful life, so it is extremely important to have the capsules replaced at the 5 year mark.

WHEN GROWTH WON'T STOP

Although the Norplant system prevents release of an egg, it will sometimes allow a follicle to begin developing. Lacking the usual hormonal cues that cause all but a dominant follicle to disappear at the end of a cycle, the out-of-control newcomer will continue to grow until it resembles a large ovarian cyst. In time, such enlarged follicles usually disappear. However, there is a slight danger of twisting or rupture, which could require surgery.

The Benefits and Risks

Scientists have noted few if any serious complications with Norplant implants, probably because they don't contain estrogen, and release their contents slowly, thereby avoiding hormonal surges. To be on the safe side, the manufacturer relays warnings based on experience with the Pill, which contains estrogen. (For risks and complications of OCs, see preceding section of this chapter.) Other possible complications include bleeding irregularities, follicular abnormalities, tubal pregnancies, harm to the infant during breastfeeding, and thromboembolic disorders. Insertion site infections can also prove troublesome.

Bleeding irregularities: Since many women have irregular periods while using Norplant implants, it's possible that more serious conditions marked by vaginal bleeding could be overlooked. These conditions include cervical and endometrial cancer.

If you're like many other women, your period may gradually stop while you're using this method, a condition known as “amenorrhea.” But if you use Norplant implants and you suddenly stop having periods after being regular, it could mean you're pregnant. If you have 6 weeks or more of amenorrhea following normal periods, take a pregnancy test.

Follicular abnormalities: In the normal reproductive cycle, many ovarian follicles compete to become the one dominant enough to produce an egg. Those follicles not quite making the grade degenerate in a process known as “atresia.” Although Norplant implants suppress the ovulatory system in about 50 percent of users, sometimes follicles do start growing. Researchers have noted that in Norplant users, follicular atresia is sometimes delayed, causing follicles to grow beyond their normal size. These growths can't easily be distinguished from ovarian cysts. Although the enlarged follicles disappear on their own most of the time, if they twist or rupture, surgery may be required.

Tubal pregnancies: Tubal, or ectopic, pregnancies do occur among women using Norplant implants, but less often than among women using no method of birth control. If you begin to feel abdominal pain, especially after your implants have been in place for a long time, seek medical care to rule out ectopic pregnancy.

Breastfeeding: Progestin­only methods like Norplant implants and Depo­Provera have no impact on breast milk production; on the contrary, some studies show that milk production increases in the presence of progestins.

When studies were conducted on the Norplant system in the United States, some of the subjects were women who had the implants placed while they were breastfeeding. Six weeks after delivery, these women were given Norplant implants, and their breastfed children were then monitored for 3 years. Small amounts of the system's hormone could be found in the infants, but it did not affect their growth or health.

Unfortunately, no American women were studied earlier than 6 weeks after giving birth, making it impossible for the Food and Drug Administration to recommend the use of Norplant implants for women right after delivery. This lack of support from the FDA makes it difficult for doctors to recommend immediate postpartum insertion, even though studies outside the U.S. have documented its safety.

The issue is probably moot, because the act of breastfeeding can provide pregnancy protection for at least 6 weeks postpartum. Women in many developing countries (and even a small number of American women) actually use breastfeeding as a means of contraception. The method, which requires breast milk to be the infant's only source of nutrition, is known as the lactational amenorrhea method, or “LAM.”

Thromboembolic disorders: Progestins are not known to cause the clots or blockages of blood vessels found in thromboembolic disease, but if you have an active case, your physician may suggest another method. If you develop any such disorder while using the implants, you should probably have them removed. If you had thromboembolic disease in the past, you are probably not a good candidate for Norplant implants.

Insertion site complications: With proper antiseptics, the insertion site seldom becomes infected. The skin can become irritated even several months after insertion, but this, too, is rare.

Nuisance Side Effects

Norplant implants can cause some of the same nuisance side effects as the Pill, including acne, breast tenderness, depression, headaches, nausea and weight gain. Other side effects that have been noted include nervousness and dizziness, skin rash, breast discharge, changes in appetite, and hair loss or growth. But by far the most common side effect of the implants is irregular bleeding.

In the many studies of the system, 60 to 100 percent of users experienced some kind of menstrual change, especially in the first few months. These changes can include bleeding for a longer time than usual per cycle (27.6 percent), spotting between periods (17.1 percent), frequent bleeding onsets (7.0 percent), infrequent or light bleeding (5.2 percent), or no bleeding at all (9.4 percent).

It is important to note that even with these irregular patterns of increased bleeding, women using Norplant implants lose less blood than women with normal menstrual cycles. Studies show that Norplant implant users have higher hemoglobin levels than nonusers do. This could prove beneficial for women prone to anemia.

Here is a list showing the rate of side effects seen during two multinational studies:

If you are concerned about potential side effects, it might be a good idea to take the implant system for a kind of “test drive” before you pay a lot of money to have the capsules inserted. You can do this by taking a progestin­only OC called Ovrette for a cycle or two. It contains the same progestin as Norplant implants, and should give you some idea of how you will react once the implants are in place.

Depo­Provera Contraceptive Injection

If a woman has trouble remembering to take oral contraceptives or can't use them because of certain medical problems, and she doesn't want to use an implant because of its long­term effects, there is now a third option: Depo­Provera Contraceptive Injection.

Depo­Provera was approved by the U.S. Food and Drug Administration as a treatment for endometrial and kidney cancer in the early 1970s, but it took nearly 20 years of research to convince the agency to approve it as a contraceptive. Officials at the FDA were concerned about studies linking the drug to breast cancer, low birth­weight babies, and osteoporosis (brittle bones).

Four Shots a Year

Depo­Provera is a shot administered in the arm or buttocks every 90 days. It contains the synthetic hormone depot­medroxypro-gesterone acetate (DMPA). This hormone is similar to a woman's naturally occurring progesterone. Although not available in America until the end of 1992, DMPA has been used for contraception by almost 9 million women in over 90 countries.

The hormone in the shot is absorbed into the bloodstream from the muscle where it was given. It provides protection from pregnancy within 2 weeks of the initial injection. Blood levels of DMPA remain high for about 4 weeks, then stabilize at a lower level.

You will probably be given a pregnancy test before your first injection because one study showed that DMPA users who were either pregnant at the time of their first shot or who got pregnant while using the drug were more likely to have low birth weight babies.

It's important that you get your shots regularly. However, if you are going on an extended vacation and need one before 3 months are up, it will do no harm. You also have a grace period of about 4 weeks after the next shot is due. It is inadvisable to push the limit though, because some women have gotten pregnant by extending their three­month intervals. Shots cost about $30 to $40 or more, depending on where you live.

If you want to stop using Depo­Provera, there's good news and bad news. The good news is that, unlike Norplant implants which require a doctor's assistance to remove, you can discontinue Depo­Provera simply by not getting your next shot. The bad news is, once you've gotten a shot, you're committed for a full 90 days.

How Effective Are the Shots?

Depo­Provera is highly effective. Only 1 out of every 300 to 400 women on Depo­Provera will get pregnant.

The Benefits and Risks

Like Norplant implants, Depo­Provera contains no estrogen and is therefore free of estrogen­related side effects. It is, however, associated with its own set of complications: bleeding irregularities, cancer risks, bone mineral density changes, low birth weight babies, tubal pregnancies, drug interaction, and problems reestablishing fertility. Although breastfeeding while taking Depo­Provera poses no problem for the infant, some experts advise women to wait 6 weeks after childbirth before getting a shot.

Bleeding irregularities: You might have irregular periods while using Depo­Provera. Since vaginal bleeding might also be a symptom of a more serious medical problem such as an infection or cancer, see your doctor if the bleeding is severe or persistent.

Cancer: Suspicion that Depo­Provera could cause breast cancer was based on high­dose animal studies later discredited by the FDA. Still, the stigma persisted. To resolve the issue, researchers in several different countries conducted studies involving thousands of women. Some of these studies found no increased risk for breast cancer, while others found a slightly higher risk among women who had taken Depo­Provera within the last 4 years and who were under 35 years of age. In June 1993, a panel of experts convened by the World Health Organization in Geneva, Switzerland, reviewed all the available data, and announced that Depo­Provera does not increase the overall risk of breast cancer. They also found no link between the drug and cervical cancer, the second most common cancer among women. Moreover, the panel stated that Depo­Provera can provide some protection from endometrial cancer.

Bone mineral density changes: During the FDA's evaluation of Depo­Provera, a study of 30 New Zealand women who had been using the drug for at least 5 years raised questions about a possible link with brittle bones. However, experts contend that the study was flawed because it involved too few women, failed to measure the women's prestudy bone density, and didn't consider such life-style factors as smoking.

The drug's suppression of a woman's naturally occurring estrogen could theoretically lead to a reduction in bone density. However, studies of women using Depo­Provera for noncontraceptive purposes have not shown this to be true. Scientists feel the results of the New Zealand study are inconclusive and that further research is needed to settle the issue.

Low birth weight babies: Women who are pregnant at the time of their first shot of Depo­Provera or who accidentally become pregnant a month or two after starting the drug are more likely to deliver babies with low birth weights. Although low-birth-weight babies are twice as likely to die as babies of normal weight, children exposed to Depo­Provera before birth and followed through adolescence show no signs of adverse health effects.

Tubal pregnancies: Tubal pregnancies can occur among Depo­Provera users, but less often than among women using an intrauterine device (IUD) or no birth control at all. If you begin to feel abdominal pain, see a doctor to rule out tubal pregnancy.

Drug interaction: The drug amino-glutethimide (Cytadren) can reduce the effectiveness of Depo­Provera. Cytadren is used to suppress adrenal gland function in patients with Cushing's syndrome and adrenal cancer.

Returning to fertility: Sixteen weeks after your last shot you should be able to conceive, but it could take 1 to 2 years for your periods to fully return to normal. In one study, more than half of the women who wanted to become pregnant conceived after 1 year; by the end of 2 years, 90 percent of women had conceived.

Breastfeeding: There is no evidence that Depo­Provera is harmful to nursing infants. However, the manufacturer takes a conservative approach by suggesting that a breastfeeding woman wait 6 weeks after giving birth before taking the medication.

Nuisance Side Effects

Depo­Provera can cause some of the same nuisance side effects as the Pill and Norplant implants: depression, headaches, weight gain, nervousness, and dizziness. As with the implant system, irregular bleeding is by far the most common side effect.

As you continue to use Depo­Provera, you'll notice less and less spotting or breakthrough bleeding, and finally will have no period at all. At the end of one year, 57 percent of women using Depo­Provera have no period, and by the end of two years, 68 percent have stopped menstruating.

Another significant side effect—probably the most undesirable one—is weight gain. Here is an example of the amount of weight gained by the average Depo­Provera user:

• After 1 year: 5.4 pounds gained
• After 2 years: 8.1 pounds gained
• After 4 years: 13.8 pounds gained
• After 6 years: 16.5 pounds gained

It seems that the weight gained by Depo­Provera users is related more to an increase in appetite than fluid retention. Reducing your fat and calorie intake and exercising regularly can help you prevent weight gain while using this method.

Whether you use Depo­Provera, Norplant, or the Pill, hormonal birth control takes the guesswork out of family planning and returns spontaneity to sex. It is the most effective method of contraception, and the risks it poses are minimal. As with any medication, it's important to watch for side effects and report them to your doctor. But, if you're like the majority of women, your problems most likely will be few. 