Tuesday, March 31, 2009

Committment Issues

One of my biggest challenges as a gyno is to match up each of my patients with a birth control that works for her. Something that seems simple...unless you've tried to be true to your birth control through every relationship, move, job change, and side effect. Which is, basically, all of us.

A 2008 report (PDF) from the Guttmacher Institute shows that almost half of women who are at risk of an unintended pregnancy--meaning they're having sex and don't want a baby--don't use birth control consistently and correctly. Some women have gaps in their use, some don't use their methods well, and others don't use birth control at all.

Why is staying on birth control so hard? Life changes make it really difficult to keep up with your pill. Who can remember--every month--to get a pill refill when you're moving/changing jobs/changing guys? Method problems are a huge factor--access, even for women with insurance, can be a problem. Some of the newer pills can have copays of $30, $40, even $50 a month...or aren't covered at all. Many plans have excluded IUDs for years, and now I'm even hearing about insurances that won't cover the NuvaRing. And hardest of all is ambivalence--not being sure that you don't want to be pregnant after all.

I often think that the most important feature of a contraceptive method is the timing of its use--more important than even side effects or effectiveness--since you have to use the method correctly for it to work at all. So if a patient is having trouble choosing birth control, I ask her:
  • Can you really take a pill every day? Seriously, it's not human nature to do this--to take medication, every day, when you're feeling well. It's one thing if you have strep throat or a UTI (and you'll take anything to feel better)--it's another when you don't feel sick.
  • Would you rather change your method every week or every month? On the surface, the patch and the ring are more convenient, since you avoid the "every day" problem of the pill. But trying to remember once a week or month may be even harder (unless you can count on your planner or Outlook to give you a reminder).
  • How about coming into see me 4 times a year? Depo-Provera has the advantage of not having to remember anything at home, beyond scheduling your next appointment. But how many women really want to visit their gyno that much?
  • So how about an IUD? I think that IUDs are ideal options for many women, because once they're placed, you can forget about it, until you're ready to have it removed. And birth control that's amazingly effective, that you don't have to pay attention to, may be the most effective method of all.
What challenges have you faced with finding the perfect birth control method?

Photo credit: ton3vita


Sarah said...

Hormonal birth control leaves me with no libido (making it very effective, but less than fun) and I’ve resisted the IUD because of the potentially ugly effects on a fetus if it fails. (This is irrational, given the low likelihood of that happening, but my second son was stillborn and it’s a bit triggering for me.) So I’ve been stuck with condoms and absolutely hate it.

Dr. Kate said...

Sarah, there's no evidence that an IUD will affect a fetus if a pregnancy happens. There's a higher risk of miscarriage if the IUD is left in - but there's been no reports of all of birth defects. So you can use an IUD without worrying about this...but I'm so sorry for your loss.

Stephanie said...

Hormonal birth control increases how often I have my period. My natural cycle is around every 45 days. On the pill I feel like I'm always just having had my period or getting ready for it. Plus I bleed more on the pill. Normally I only bleed for a day and half on the pill it's three days. Plus I think I'm more moody on the pill.

Dr. Kate said...

Stephanie, that's so rotten - most women have better periods on the pill, and I think you're one of the few where it gets worse! You might want to consider the NuvaRing or the Mirena IUD - this IUD in particular is known for making many women lose their periods altogether.

Jennie said...

I can't take hormonal birth control because they increase my incidence of debilitating migraines (multiple times a week compared to once every few months normally). I tried the normal pill and the mini pill (low dose progesterone), but had the same reaction with both. I won't try anything I can't stop right away, like the deproprovera shot, because of this. I have given up on hormonal BC. Currently I use spermicide and condoms, but I'm in a long term monogamous relationship and would like to get an IUD (paragard), but the cost is prohibitive.