Not Your Mother's Birth Control

Reading a popular women's magazine the other day, I was startled to discover that what looked like one of those peel-off makeup samples wasn't a makeup sample at all. It was "The Patch"--a new form of birth control that you slap on your skin once a week. Of course, the magazine sample didn't actually contain the combination of estrogen and progestin that the real patch releases--it was just to demonstrate how thin and unnoticeable the real thing is.

A few pages later, I found an ad for NuvaRing, an insertable hormonal contraceptive. After decades of little to no exciting news in contraceptives for women, suddenly we're riding a wave of promising new birth control methods.

"This is really unprecedented. It's been a revolutionary year," says Stephanie B. Tiel, M.D., a clinical instructor of obstetrics and gynecology at Columbia University College of Physicians and Surgeons in New York. "There are four new FDA-approved methods of contraception now on the market." Tiel calls the new options "the best of both worlds"--they have the quick reversibility of the Pill, should you decide to get pregnant, but they're longer-acting systems that don't require busy women to remember to do something at the same time every day.

"You Don't Have to Think About It"

First on the market was Mirena, an intrauterine device (IUD) that's been used in Europe for over ten years. Mirena releases levonorgestrel, a hormone commonly found in the pill, to create a "hostile uterine environment" and prevent pregnancy. Inserted (and removed) by a physician, Mirena works for up to five years, with a failure rate of less than 1%.

"You don't have to think about it. Once it's in, it's in," says Tiel. "It's just as effective as having your tubes tied, only it's reversible." Another big plus: Mirena means lighter periods for most women. In fact, some 20% of Mirena users don't menstruate at all. "It's totally normal. The hormone in the IUD thins the ¼ lining [of the uterus] so you still ovulate, but you don't bleed," Tiel explains. Most of the other 80% experience 1-2 days of very light bleeding--a huge relief if you normally have problem periods.

Some women avoid IUDs because of fears of infection and infertility. But those problems were limited to the Dalkon Shield, which had a braided string for the doctor to use in removing the device. The braiding allowed bacteria to grow, unlike the single-filament strings used to remove Mirena (and the other current IUD, the copper-IUD).

As with any birth control method, there are some disadvantages. Mirena has to be inserted and removed by a doctor--it's a simple, painless procedure, but not a do-it-yourself task. It's also expensive, costing about $360 for the device plus your doctor's visit fees, if your insurance doesn't cover it (some plans do).

Following on Mirena's heels came Lunelle, a monthly hormonal injection. Unlike Depo-Provera, women still menstruate with Lunelle, which has a ten-day "window" for each new dose. In other words, if you got your last Lunelle shot on October 10th, you can get your next one any time from the 5th to the 15th of November without dampening its effectiveness.

Lunelle's effectiveness, at 98-99%, is equivalent to that of the birth control pill if the woman's compliance is good--and since you only have to take the shot once a month, compliance should be higher than with a once-a-day pill. Disadvantages? Some women don't like shots, and the monthly doctor visits can be inconvenient.

Patching It Up

Tiel predicts that Ortho Evra, the birth control patch, will be immensely popular. Using the same hormones as in the most popular birth control pill, Ortho Tri Cyclen, the patch can be applied anywhere on the body--the buttocks, the lower back, the abdomen--except directly over the breast. "It's discreet. People don't have to see it if it's under your underwear," she says. It's changed once a week, and has the same side effect profile as the pill.

The big difference: patch compliance rates are much higher than with the pill, especially for younger women. Teenagers, for example, only manage effective pill compliance 67% of the time, but with the patch, they use it effectively 88% of the time. The patch does occasionally come loose--about 3% of the time--and users need to check once a day to make sure it's still firmly in place.

Finally, there's NuvaRing, a small, flexible transparent ring about as big as a silver dollar, that a woman inserts directly in her vagina. It's replaced every three weeks, and because it's not a barrier method but acts by releasing hormones, it doesn't need to be precisely placed to be effective. "So as long as it's up in the vagina and exerting influence using the hormones, it's fine," says Dr. Tiel. "You just squeeze it and slip it in, and you don't feel it while it's there."

Like the pill, NuvaRing has a pregnancy rate of less than 1%. NuvaRing, OrthoEvra, and Lunelle also have the same counterindications as the pill--for example, smokers (especially those over 35) are at increased risk of blood clots, and women who have blood clots, certain cancers, or a history of heart attack or stroke are advised against using these methods.

Tiel doesn't think the new options, as exciting as they are, will replace the pill. "The pill probably is still going to be the mainstay contraceptive for women. The point is that some women will do better with the ring, some with the patch, and so on," she says. "Everybody should have the best chance to have maximum success with their contraception."

Originally published Oct. 31, 2002.