Birth Control Options: The Cedar River Clinics’ Birth Control Chart

By Ginny Cassidy-Brinn, and Joan Schrammeck
Cedar River Clinics, Washington

When selecting a birth control method, a woman has many questions, such as how to use the method, how well it prevents pregnancy, and what side-effects it might have. Because a woman is fertile for 30 or more years, she will probably use more than one method in her lifetime. No single method is best for everyone. Each woman needs to find what fits her needs, lifestyle, and health background.

Cedar River Clinics publishes the Birth Control Comparison Chart, a tool to compare and contrast options, and an informational website with information about each method. This article summarizes information from the Cedar River Clinic’s Birth Control Comparison Chart, created for use in community education and with clients in its abortion, birth control and well-woman clinics. It describes methods that are currently available in the U.S. Information about ordering the chart is at the end of the article.

Barrier Methods: Diaphragm, Cervical Cap, Female/Male Condom, Spermicides, Sponge

Barrier methods create a physical, chemical, or combination barrier over the cervix or penis to prevent egg and sperm from meeting. Caps and diaphragms require a clinic visit and a prescription. The other methods are available over-the-counter. The most significant benefit of condoms is that they prevent the spread of HIV and other sexually-transmitted infections (STIs). Cervical barriers may offer some limited protection against some STIs. Using a condom in combination with another method (except another condom) significantly decreases the risk of pregnancy and offers protection against HIV/STIs. Caps, diaphragms and sponges are not recommended for women who have had Toxic Shock Syndrome.

Male Condom – 85-98 % effective

A male condom is a sheath, usually made of latex, which fits over the erect penis. Male condoms provide a thin protective layer between partners so that bodily fluids (semen, blood, or saliva) are not shared. This male-controlled method is only effective when the condom is put on just before sex. A new condom must be used each time. A wide variety of styles, colors, and types are available. Some people have an allergic reaction to the rubber and/or spermicide that can be used in latex condoms.

Female Condom – 79-95% effective

A female condom is a thin, loose, flexible plastic tube worn inside the vagina. A soft ring at the tube’s closed end covers the cervix, while the open end remains outside the vagina and partly covers the lip area. Female condoms can be inserted up to eight hours before intercourse. The female condom can be difficult to insert at first, is more expensive than male condoms, and may be more noticeable during sex. Only one style of female condom is available today, but new styles and brands are under development because the female condom is an important woman-controlled means to protect against HIV/STIs.

Spermicides – 71-82% effective

A spermicide kills or disables sperm so that it cannot cause pregnancy. Spermicides come in many different forms -- foam, jelly, cream, film, and suppositories – and most use the chemical nonoxynol-9. Spermicide is inserted by the woman into her vagina before intercourse and more added for subsequent intercourse. Spermicide should remain in the vagina for eight hours after sex because sperm can stay alive that long. If spermicides irritate the vagina they can make it easier to contract HIV/STIs. Some people are allergic to certain spermicides, which can cause genital irritation, rash, or itching. Combining the use of condoms and spermicide is extremely effective — as effective as using birth control pills.

Contraceptive sponge – 80-91% effective

A contraceptive sponge is a small soft, round piece of foam that is filled with spermicide that is gradually released into the woman’s vagina over a 24-hour period. It can be inserted well before intercourse, up to 24 hours before sex, and it works for multiple acts of intercourse. Because it is soft, the sponge is usually not felt by the woman or her partner. It should be left in place for 6-8 hours after intercourse because sperm can stay alive in the vagina for that long. There is only one brand of sponge approved for sale in the United States. Other sponges are sold in other countries and are available on the Internet, but they are not regulated or approved by the U.S. our government so there is no assurance that they are effective and safe. Sponges are less effective (40-80% effective) in women who have given birth. Research also indicates that sponge use increases the risk of HIV, at least among commercial sex workers who use them many times a day.

Diaphragm – 86-94% effective

A diaphragm is a thin rubber dome with a springy, flexible rim. It is filled with spermicide and inserted into the vagina to hold the spermicide in place over the cervix. A diaphragm can be inserted up to two hours before sex and should be left in place for 6-8 hours after sex. A diaphragm is fitted in a clinic to the size of a woman’s vagina. Pregnancy and weight changes affect the size of a woman’s vagina and make a refitting necessary. Some women are allergic to the diaphragm and/or spermicide and can’t use the method. Bladder infections are the most frequent side effect.

Cervical Cap – 84–91 % effective

A cervical cap is a thimble or cap-shaped device smaller than a diaphragm that fits snugly over the cervix. It can be put into the vagina up to 48 hours before sex. Cervical caps can be filled with spermicide. After intercourse, the cap should be left in place for eight hours. Getting a cap requires a prescription and a clinic visit to learn how to use it. Insertion and removal become easier with practice.

Two primary cervical barriers are available in the United States: FemCap and Lea’s Shield. FemCap is made of silicone and comes in three sizes. Lea's Shield, also made of silicone, comes in one size. It has a loop to help with insertion and removal and a valve that allows menstrual and cervical secretions out. The Prentif cap is no longer being manufactured, but some clinics still have it in stock. Prentif cannot be used by women who are allergic to latex. Caps are less effective in women who have given birth (68-74% effectiveness). Giving birth affects the cap’s fit, so women should have this checked after childbirth.

Knowledge-Based Methods: Withdrawal, Fertility Awareness, Abstinence

Methods that rely on behaviors or knowledge are available without prescription. For some, a high degree of knowledge is required (e.g. fertility awareness); for others, trust and commitment are the relevant factors (e.g. withdrawal, abstinence).

Withdrawal – 73-96% effective

Withdrawal (coitus interruptus) is a very commonly used method in which the man removes his penis from his partner’s vagina before ejaculating. Withdrawal prevents contact between egg and sperm, thereby reducing the possibility of pregnancy. Withdrawal is one of the few methods for which men can take responsibility. It depends on the man’s self-knowledge and control, which can be affected by substance use or lack of sexual experience. Withdrawal is much more effective than not using any birth control. Many health professionals have a misconception that sperm is contained in pre-ejaculate, but this is not borne out in scientific studies. To remove any stray sperm that may remain from a previous ejaculation, the man should urinate and wipe the tip of his penis before intercourse. Partners who are less experienced with withdrawal may have a higher risk of pregnancy during their first attempts with this method. To increase effectiveness, they may also want to use spermicide or fertility awareness methods.

Fertility Awareness Method – 80-98% effective

Fertility Awareness is a combination of methods in which a woman learns the most and least fertile times in her monthly cycle, and uses this information to encourage or prevent pregnancy. Information is gathered by tracking the consistency of cervical mucus, position of cervix, body temperature, and the length of menstrual cycles. The consistent, daily monitoring required takes time. For some women this is an exciting discovery process as they learn more about their bodies. Fertility awareness requires self-control and couples must use an additional method if they want to have intercourse during the part of the month when the woman is most fertile. New technologies such as calculators, computer programs, saliva and urine tests, as well as simpler cycle beads, may aid in using this method. This method does not protect against HIV/STIs.

Abstinence – 100% effective?

Abstinence can be defined as no sexual contact at all, or as no contact that could cause pregnancy or STIs. As a method of birth control, abstinence does not necessarily mean refraining from sexual pleasure and it can result in a better understanding of one’s body, better communication between partners, and more sexual satisfaction. Abstinence may include sexual exploration, mutual masturbation, oral or anal sex, or use of sex toys. Contact with bodily fluids (blood, semen, or vaginal secretions) carries the risk of STI transmission. Oral sex, anal sex, and the use of sex toys do not protect against HIV/STIs unless a barrier like a condom or dental dam are also used. While abstinence is 100 percent effective when used consistently, it can be hard to maintain. Abstinence can be important when there are health situations that make intercourse dangerous or difficult. If abstinence involves a strict moral pledge that is not realistic for the people involved, however, guilt and failure are more likely.

Hormonal Methods: Contraceptive Patch, Depo Provera, Oral Contraception, Mini-Pill, Vaginal Ring, Emergency Contraception

Hormonal birth control adds synthetic hormones (estrogen and progestin combined, or progestin alone) to the woman’s body. The hormones prevent ovulation (release of an egg from the ovary), affect the uterine lining, thicken the cervical mucous, and impede sperm movement – actions that, together, prevent fertilization. The hormonal dose varies; injections have the largest, longest-lasting dosage. All except EC require a prescription (women under 18 need a prescription for EC). Women should not use estrogen-containing methods (except EC) if they are over 35 and smoke, or have certain conditions (including heart disease, blood clotting disease, certain cancers, or liver disease). Effectiveness may be reduced by medications including antibiotics, migraine medications and St John’s Wort. The pill, patch and ring may cause nausea, breast tenderness, weight gain or loss, water retention, increased blood pressure, headaches, and mood changes. Hormonal methods do not protect against HIV/STIs.

Contraceptive Patch – 92-99% effective

The Contraceptive Patch is applied to a woman’s skin and changed weekly (three weeks on, one week off). It affects fertility for one month at a time and becomes effective in 7 days. It is slightly less effective in women weighing 198 pounds or more (92% vs. 99% percent effective). Some women experience skin irritation at the patch site. Women receive more synthetic estrogen from the Patch than from low-dose Pills or the Ring. Since it is one of the newest methods available, research has not yet been done on whether this increases the risk or blood clots, heart attacks, or stroke.

Depo-Provera – 97-99% effective

Depo Provera (also called DMPA) is an injection of synthetic progestin that prevents pregnancy for three months. Depo Provera is very private (it cannot be seen on the body and requires no home supplies). It requires a clinic appointment every three months. It becomes effective in 24 hours if the shot occurs within five days of the beginning of a woman’s menstrual period. Depo Provera may be used by smokers over age 35 because it contains no estrogen. It is not recommended for women with unexplained vaginal bleeding, who want to become pregnant in the near future, are concerned about weight gain, or have certain medical conditions (including liver disease, gallbladder disease, or depression). Most significantly, nearly every woman experiences menstrual changes and Depo Provera is not reversible. Some women have strong reactions (including headaches, mood changes, breast tenderness, weight gain). If these occur, there is no way to get the medication out of the body and symptoms can last longer than the three months of reliable contraceptive protection. Also, it may take much longer than three months for a woman’s fertility or regular cycles to return after the last shot. Depo Provera is associated with a loss of bone density and increased risk of osteoporosis and is therefore not recommended for long-term use, particularly for young women whose bones are still growing.

Oral Contraception – 92-99% effective

Oral Contraception (The Pill) is the most popular type of birth control in the U.S. The Pill is taken daily for 21, 28, 91 or 365 days and becomes effective in 7 to 28 days. It stops a woman’s normal menstrual cycle. With the 21- or 28-day pack, bleeding occurs monthly. A woman who uses the 91-day pack will bleed approximately four times per year. A woman who uses the 365-day pack will probably stop bleeding altogether, although many women experience a great deal of unexplained bleeding during the first few months of long-duration pills – often as much as would have occurred on the regular Pill. They can cause lighter or more regular periods and reduce acne; they do not impact future fertility.

Mini Pill (Progesterone Only Pills) – 87-99.7% effective

Mini-Pills are progesterone-only birth control pills containing a synthetic form of progesterone. Each Mini-Pill contains hormones; there are no spacer pills as with a 28-day cycle of the Pill, and it becomes effective in 7-28 days. A woman must take a pill every day at the same time. If she misses even one pill, or takes it at a different time, she increases the chance of pregnancy. Since Mini-Pills contain no estrogen, they can be used by women with certain health conditions who cannot take regular birth control pills. Mini-Pills increase the risk of functional ovarian cysts, ectopic pregnancy, and irregular bleeding and may cause irregular bleeding/spotting or a lowered sex drive. Some of the typical effects of regular birth control pills (nausea and breast tenderness) usually do not occur with Mini-Pills.

Vaginal Ring – 92-99% effective

The Vaginal Ring is a thin, transparent, flexible ring that is inserted into the vagina, where it slowly releases synthetic estrogen and progestin. The Ring is worn continuously for three weeks followed by a week off, or can be worn continuously to avoid having a period. It is effective in seven days and affects fertility for one month at a time when not worn continuously. Women with certain family medical histories (such as breast cancer, diabetes, high blood pressure or cholesterol, and epilepsy) may not be able to use it Effects may include vaginal irritation and irregular bleeding.

Contraceptive Implant – over 99% effective

The contraceptive implant is a soft capsule, about one inch long, which is inserted under the skin in a woman’s upper, inner arm. It constantly gives off tiny amounts of the synthetic hormone progestin and lasts for three years. A clinic visit is required. It is usually inserted within five days after the start of a woman’s menstrual period (to ensure that she isn’t pregnant). A backup method is recommended for the first two weeks after insertion. When the implant is inserted, the clinic provides a card with insertion and removal dates. While the implant can be removed at any time, it is not reliable for birth control after its removal date. Most women with implants experience changes in their menstrual periods; usually this is less bleeding overall, but ranges from daily light spotting to irregular bleeding, to no periods, to heavier bleeding. A possible side effect is infection at the implant insertion site. It is possible that the implant could be difficult to remove. Implants are not recommended for women with heart disease, unexplained vaginal bleeding, liver disease, breast cancer, or allergies to anything in the implant. Women over 130 percent of their ideal body weight may not get a large enough hormone dose to prevent pregnancy.

Emergency Contraception (EC)

Emergency Contraception prevents pregnancy after intercourse through a short burst of synthetic hormones. The sooner EC is taken, the more effective it is, so it is more effective one hour after unprotected intercourse than ten hours later. Pregnancy prevention can be attempted up to five days after intercourse. Large doses of some types of regular birth control pills also work as EC. Plan B EC is available over-the-counter for those aged 18 or older; women under 18 need a prescription. Women may buy it in advance to have on hand. EC has no impact on an existing pregnancy. Plan B can be used if a woman is raped, if a condom breaks, or any time prevention wasn’t used during intercourse. EC’s effectiveness rating differs because it is based on reducing the risk of one specific pregnancy rather than pregnancies over the course of a year.

Intrauterine Device (IUD) – 99% effective

An IUD is a small plastic device inserted through the cervix into the uterus, where it changes the uterine chemistry that alters the movements of eggs and sperm and prevents fertilization. The IUD does not cause an early abortion. Getting an IUD inserted involves a clinic visit; removal can happen at any time and is quicker and easier than insertion. It is effective immediately. IUDs are not recommended for women who have serious uterine infections or certain types of cancer; women with uterine fibroids may not be able to use it either. A small string extends from the IUD into the vagina; women who are unable to feel in their vagina for the IUD string, or who don’t have access to medical care in case of pregnancy, might not be able to use the IUD. There is a small chance the IUD could affect a woman's fertility due to uterine perforation, embedding in the uterine wall, or pelvic infection. IUDs do not protect against HIV/STIs; further, STIs could become more dangerous, more quickly, if an IUD is in place.

There are two types of Intrauterine Devices: one contains copper and the other contains a small amount of hormone. The Copper IUD can last for ten or more years. It has a tiny copper wire wrapped around the plastic body and should not be used by those allergic to copper. Some women experience longer, heavier, more painful menstrual periods that may lead to anemia. The Hormone IUD slowly releases small amounts of synthetic progesterone which helps reduce bleeding and cramping associated with the device. It lasts for five years. Women who have liver disease may not be able to use it. Most women eventually stop having any menstrual periods. This can help in treatment of anemia due to heavy menstruation. The hormone IUD can cause irregular bleeding, ovarian cysts, weight gain, headaches, increased blood pressure, acne, depression, and decrease in sex drive.

Permanent Birth Control through Sterilization: Vasectomy, Tubal Ligation

Sterilization is a surgical procedure that prevents men’s sperm and women’s eggs from traveling through their respective tubes inside the body. It is permanent birth control and regret may occur. While reversal is possible, the chance of pregnancy after reversal is not good. Vasectomy is a less complicated surgical procedure than tubal ligation. Sterilization does not protect against HIV/STIs.

Male Sterilization – 99.9% effective

Male sterilization occurs through vasectomy, a procedure that closes or cuts the vasa deferentia (the tubes inside the scrotum) that carry sperm, thereby stopping sperm from mixing into the semen when men ejaculate. No sperm leave the man’s body but semen production is unaffected. It does not affect sexual performance. The outpatient medical procedure is performed in a clinic or doctor’s office. Vasectomies become effective after one month or 10-30 ejaculations. Men usually return to the clinic for a test to be sure the semen is clear of sperm.

Female Sterilization — 99.5% effective

Female sterilization occurs through tubal ligation, an outpatient procedure to close, cut, tie off, or burn the fallopian tubes to stop the passage of eggs. It is done in a clinic, doctor's office, or hospital and is effective immediately. A newer, chemical, non-surgical procedure to block the fallopian tubes can be done in a doctor’s office or clinic.

About Effectiveness Rates

Effectiveness is defined as the rate of pregnancy per 1,000 women over one year’s time. If no birth control is used, 85 percent of sexually active women will get pregnant in one year. Effectiveness ratings range from a lower percentage that occurs when the method is typically used by women or men in their everyday lives (called “use” effectiveness), to a high percentage that occurs when the method is used correctly and consistently or perfectly (called “theoretical” effectiveness). Pharmaceutical companies often cite perfect use for their own product and real-life effectiveness for other methods. Methods that involve active participation and decision-making by the user (such as condoms) tend to have a lower use effectiveness rate and a bigger spread between the theoretical effectiveness and the use effectiveness rates. This does not mean the method is inferior, however.

Effectiveness is not the only consideration when choosing birth control. Women themselves, even young women, are the most qualified to determine which methods will work best in their particular life circumstances. The comparison chart includes unbiased information on methods that are often ignored by professionals such as abstinence and withdrawal. Statistics aside, the most effective method is the one that the particular woman can actually use.

A Note About Breast Feeding

Breast feeding is 98-99 percent effective as birth control, but certain conditions are necessary. She must be breast feeding exclusively (not using formula or baby food), with feedings no more than four to six hours apart, and it must have been less than six months since she gave birth, and her periods must not yet have returned. A woman who is breastfeeding may want to avoid hormonal birth control, to avoid passing the hormones on to her baby through breast milk.

A Note about Abortion

Women use birth control to prevent pregnancy. If contraception does not work and pregnancy results, however, a woman must decide between parenting, adoption, or abortion. Abortion does not affect a woman’s ability to get pregnant in the future.

For More Information

The Birth Control Comparison Chart is a two-sided bilingual English and Spanish brochure, which can be ordered by calling 206.267.2701 x1512, or sending an email to JoanS@CedarRiverClinics.org. Visit www.Birth-Control-Comparison.info for detailed information about each method. Special thanks to Holly Beale of Two Dragons Design for the wonderful illustrations and chart design.

Ginny Cassidy-Brinn is an ARNP and Joan Schrammeck is Communications Director at Cedar River Clinics, the Feminist Women's Health Center in Washington State.