Women's Bodies, Women's Wisdom (88 page)

Oral Contraceptives (The Pill)

Oral contraceptives have been a boon for many women, though they may contribute to suboptimal nutrition and an increased incidence of yeast infection in many (the pill has been associated with lowered serum levels of B vitamins and other metabolic changes).
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It is also associated with a slightly increased risk for cervical adenocarcinoma,
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elevated triglyceride levels,
¹⁵
and systemic lupus erythematosus.
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Although the announcement didn’t get much press in the United States, the World Health Organization has classified birth control pills with combined estrogen and progestin (as well as combined-hormone HRT) as carcinogenic. (The latest such designation came after the cancer research agency of the World Health Orga nization convened a group of twenty-one scientists from eight countries in France in June 2005. Reviewing the scientific literature on the pill and cancer, the group pointed to evidence for an increase in cervical cancer, breast cancer, and liver cancer in making its decision, while also stressing that convincing evidence existed for a protective effect against endometrial and ovarian cancers.)
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Yet other authorities don’t think the slightly increased relative risk for breast cancer is significant.
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In my experience, the pill is also associated with mood swings, weight gain, and decreased sex drive in many women.

Going off the pill makes many women feel much better, although not all symptoms always subside. Ironically, new research is showing that oral contraceptives might actually contribute to long-term sexual dysfunction in some women. The January 2006 issue of the
Journal of Sexual Medicine
reports that the pill lowers levels of testosterone, even after the women have stopped taking oral contraceptives. Such prob lems occur because pill users have elevated levels of a protein called sex hormone binding globulin (SHBG) that binds testosterone, rendering it unavailable for use by the body. Such low values of “unbound” testosterone potentially lead to side effects such as decreased desire, arousal, and lubrication and increased sexual pain. Although the research showed that such problems persisted even after the pill was discontinued, long-term studies are still needed to determine if the problems are permanent.
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Health benefits of the pill include lowered risk of ovarian cancer, en-dometrial cancer, acne, and pelvic inflammatory disease. In general, the pill’s benefits outweigh its risks for the vast majority of women because the health risks from unintended pregnancies far outweigh any risk from the pill. Women who are on the pill should take a good multivitamin-mineral supplement containing B complex. The majority of women who have serious health problems with the pill are smokers. Smokers should not use the pill after the age of thirty-five. Oral contraceptives are now being used for women right up until menopause, at which time these same women may start on estrogen replacement therapy. Such women are on chemical birth control or hormone replacement for most of their adult lives. When a woman uses hormones in this way, she misses out on the messages she’d normally get from her uterus and ovaries (as discussed in chapters 6 and 7).

The Ring (NuvaRing)

The contraceptive ring, approved by the FDA in 2001, is a flexible ring about two inches in diameter that is inserted into the vagina and held in place by the muscles in the vaginal wall. The ring is worn con tinually for three weeks (including during sex) and then it’s removed for seven days to allow a menstrual period. After seven days, a new ring is inserted.

Like the pill, the ring contains low doses of estrogen and pro gestin, which are absorbed by the walls of the vagina and distributed throughout the bloodstream in a steady supply to suppress ovulation. Because users don’t have to remember to take a pill at the same time each day, women who use the ring have fewer hormonal ups and downs. As with the pill, users also experience more regular, lighter, and shorter menstrual periods, and fertility returns quickly after use of the product is stopped. When used as directed, the effectiveness rate is 99 percent.

Initial side effects are similar to those of the birth control pill and include weight gain or loss, nausea, moodiness, and breast ten derness. However, some users have also reported increased vaginal discharge, vaginitis, and irritation. The risk of getting blood clots may also be greater with the type of progestin in this product than with some of the low-dose pills on the market. As with the pill, women over the age of thirty-five who smoke should not use this form of birth control.

In addition, certain medicines—including the antibiotic rifampin, certain drugs used to treat mental illness or to control seizures, certain oral antifungals prescribed for yeast infections, or certain HIV protease inhibitors—may make the ring less effective. (For more information, see
www.nuvaring.com
.)

The Patch (Ortho Evra)

The birth control patch, also approved by the FDA in 2001, is ap plied to the upper arm, upper torso, abdomen, or buttocks, and replaced once a week for three consecutive weeks. It’s then removed for one week to allow a menstrual period. Like the ring, the patch delivers a steady flow of estrogen and progestin absorbed into the bloodstream to prevent ovulation. It’s also 99 percent effective when used correctly.

Most side effects are similar to those of the pill, although trials showed that breast discomfort and dysmenorrhea are significantly more common in women using the patch than in those using the pill. Also, the estrogen levels in women who use the Ortho Evra patch are 60 percent higher than estrogen levels in women taking standard birth control pills. The increased estrogen may raise the risk of blood clots (some of which are fatal) and may also, after several years of use, cause other side effects as well. Studies are currently looking into the risks of this higher estrogen level.
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Some women also report an increase in depression, changes in sexual desire, and a skin reaction at the site where the patch is applied.

The patch may also be less effective for women weighing over 198 pounds, those taking St. John’s wort, or those using the same medica tions listed above that make the contraceptive ring less effective. And as with the ring and birth control pills, women on the patch who smoke are at greater chance for cardiovascular problems. (For more information, see
www.orthoevra.com
.)

Progestin-Only Contraceptives

Depo-Provera (an injection that’s given every twelve weeks) and Implanon are both made from synthetic progestins. Implanon is a thin and flexible plastic implant (about the size of a matchstick) that is inserted under the skin of the upper arm using local anesthesia. It protects against pregnancy for up to three years.

Synthetic progestin of all kinds can result in headache, bloating, and irritability in some women. This last effect is so common that a professor of ob-gyn with an interest in natural hormones once remarked, “It’s no wonder Depo-Provera works for birth control. It makes women so ornery, they don’t want anyone near them.” A 2009 study showed that about one-quarter of Depo-Provera users experienced more than a 5 percent weight increase within the first six months of use. This weight gain was specifically linked to increased abdominal fat, a known marker for metabolic syndrome, which in turn is associated with increased risk for cardiovascular disease, stroke, and diabetes.
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Irregular spotting and acne are other problems with these methods. On the other hand, they are highly effective and “automatic” compared with other methods, and they work well for some women.

Note: The Mirena IUD also contains synthetic progestin, which may have some of the same side effects as above. It is effective for up to five years.

Barrier Methods

A wide range of barrier contraceptive methods are available. Condoms have the distinct advantage of protecting individuals from STDs. Many couples alternate between condoms and diaphragm use, thus sharing responsibility for contraceptives. See
table 6
(page 410) for a list of barrier contraceptive options, all of which have their place.

Outercourse

Outercourse is just about any form of sex play that does not involve intercourse, making pregnancy impossible (as long as care is taken that no semen gets onto the vulva or in the vagina). Some of the most com mon forms include oral sex and manual stimulation, which can be just as satisfying— and sometimes more satisfying—than intercourse. Activities such as erotic massage, fantasy, and role-playing and the use of vibrators or other sex toys also fall into this category. As long as it also eliminates exchange of bodily fluids, outercourse also reduces the risk of sexually transmitted diseases. Another big benefit of outercourse is that it can enhance orgasm because, like foreplay, it helps build excitement. (See Steve Bodansky and Vera Bodansky’s book
Extended Massive Orgasm
[Hunter House, 2000] for great instructions.)

Fertility Awareness: Natural Birth Control

My colleague Joan Morais teaches natural birth control at the University of California, Davis. She wrote, “The most common response I have gotten when I tell people I am a fertility awareness instructor is ‘Is this the method that Catholics have used that doesn’t work?’ They presume it is the old and unreliable rhythm method that Catholics used many years ago. They have already made up their minds that it sets women back a hundred years and takes away our reproductive freedom. I can relate, as I also used to think this. I opposed natural family planning and I thought the birth control pill was the best thing ever. I took the birth control pill on and off until my late twenties. I didn’t do well on it. I couldn’t feel my cycles. I couldn’t feel my body! I became depressed and I lost my libido. Somewhere inside me I had an innate wisdom that was telling me that the birth control pill wasn’t right for me.

“There is another way besides chemical contraceptives, devices, and sterilization. Fertility awareness is a beautiful way that allows a woman to feel her cycles as she wanes or waxes while also preventing pregnancy. This fundamental knowledge of a woman’s fertility and infertility should be taught to every menstruating girl and woman. It is our birthright. These are the operating instructions of our female body that somehow got thrown out along the way. Fertility awareness includes natural birth control, knowing your cyclical body, your menstrual cycle, your repro ductive health, and your fertility and infertility. To know how to prevent pregnancy naturally or to consciously know when you can become pregnant is the most profound and empowering knowledge a woman can learn. There are only five days a month a woman may become pregnant, yet we medicate our bodies twenty-four hours a day, three hundred and sixty-five days a year. This is like medicating our body every day to prevent a monthly headache.”
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I completely agree with Joan and wish I had learned about fertility awareness years ago. Though it’s not well known, fertility awareness and natural family planning are well studied and very effective.
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Joseph Stanford, M.D., a family physician and expert in natural family planning, defines fertility awareness or fertility appreciation as “the use of physiologic signs and symptoms of the menstrual cycle to define the fertile and infertile phases of the menstrual cycle. This information can be used for natural family planning or the diagnosis and treatment of infertility.” Fertility awareness involves learning how to determine your time of ovulation. While studies have shown that some symptoms associated with ovu lation in some women, such as breast tenderness, mittelschmerz (midcycle pain associated with ovulation), and change in the position of the cervix, may not be accurate indicators of ovulation, there are reliable techniques for assessing the fertile phase.

These include cervical mucus checks, observation of vaginal discharge of cervical mucus, or measurement of basal body temperature (BBT).
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Observation of cervical mucus, combined with monitoring BBT and other symptoms that occur around ovulation, is called the symptothermal method of natural family planning. But in a comparative study of fifteen different methodologies, including variations of the most common methods used to determine ovulation, it was found that the observation of vaginal discharge alone, known as the Ovulation Method, was the most precise and practical way to determine time of fertility.
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(The addition of basal body temperature graphs did not improve accuracy over the mucus discharge alone.)

Commercially available ovulation indicators that test urine pre- and postovulation are also available in most pharmacies, but it is much easier, and cheaper, to learn how to determine your own ovulatory time from changes in cervical mucus. Salivary testing can be very helpful, too (see page 403). I also recommend a highly detailed and feature-rich software program and book called
Taking Charge of Your Fertility
that details the very successful methods developed by Toni Weschler, M.P.H. The fertility software not only automates Toni’s methodologies but also allows for individual preferences and personally tailored formatting, forecasting, charting, and reporting. Plus there’s a community section that allows women to share information with one another. (See
www.tcoyf.com
.)

The advantage of becoming familiar with your fertility cycles simply through the changes in vaginal discharge over the month is that you will be able to tell beforehand when you are becoming fertile. This is very empowering, and it helps women embrace their fertility when they want to conceive and avoid conceiving when they don’t wish to become pregnant. Dr. Stanford told me, “When a couple uses this method, they often develop a deep respect for each other, for their fertility, and for their sexuality. This enhances all aspects of the relationship. It is a spiritual thing.”