No Name Not the Same?

Dear Dr. Kate,

A few months ago, I read (on a reputable website) that generic birth control pills can sometimes not be as effective as their name brand counterparts because they do not always contain the same amount or combination of hormones. I am a poor college student, so $5 for pills each month sounds way better than $30, but not if I'm not getting the same amount of protection. I'd gladly pay the extra $25 if it meant significantly higher protection from pregnancy. Is it true that generic pills are less effective? And if they are, are there any certain generics that are better than others?

Scared of Generics

Dear Scared,

That's a great question. The FDA mandates that brand-name drugs and their generic versions need to be chemically the same drug. Generic pills have to have the same active ingredients, the same dosing, and the same kind of absorption. What’s different? Colors, shapes, imprints and preservatives…but the medication is the same.

So why do some women claim to see huge differences when they switch to the generic form of their favorite pill? It may be a reaction to the inactive ingredients in the new pill; these ingredients don’t affect how the pill works to prevent pregnancy, but intolerance of them may cause side effects. The other reason is a bit more high-school-chemistry, and is related to the bioavailability of the drug. Bioavailability is the amount of time it takes the drug to be metabolized by the body. The makers of generic pills must show that the bioavailability of their generic is not significantly different (plus or minus 20%) from that of the name brand. So generics have the same amount of hormones, but it may take a different amount of time for your body to absorb it. This difference shouldn’t change the efficacy of the pill, either, but it may cause side effects in women who are sensitive to small changes in hormone levels.

All pill manufacturers have to guarantee that the hormone doses in each pill are what they claim they are, plus or minus this 20%. So that gets a little scary with ANY pills, especially the ultra-low-dose ones (with 20mcg of estrogen), because what if you get a batch that has a bunch of pills that err on the low side? That's one of the reasons I'm not a fan of the ultra low dose pills...but the same concerns apply to generics AND brands.

My advice is that if the cheaper generic pills don't cause any crazy bleeding or other side effects, stick with them. And if one generic pill makes you feel bad, you can always try another - I'd hate for anyone to stop using the pill simply because of cost.

Photo credit: spentpenny

The 40-Year Old Virgins

Okay, so she was really 35 years old. But when L., a new patient, revealed to me that she hadn’t yet had sex, she really meant no sex—not the Clinton version of sexual relations, but no penetration or orgasms of any kind with a partner. L. had decided that she was finally ready, but was anxious about what it would be like. Her friends, upon hearing that L. finds tampons uncomfortable, told her, “You’re screwed. You’d better see a doctor for advice.” The irony of “screwed” aside, this was a less than considerate response to L’s concerns.

The average age of first intercourse is around 17 years in the U.S., and roughly 90 percent of us have done the deed by age 24. But that leaves a good number of our sisters who are delaying the first time until their late 20s or beyond. It may be for religious reasons, or cultural, or the mess factor…or one (or more) of a thousand reasons. And given that we’re living in a time when nearly everything is now okay—anal sex, threesomes, vibrators that sing, etc etc—we should be really support all the choices that women make on the subject. Which, of course, includes choosing not to do any of those things, or waiting until the perfect guy, the perfect moment. If a virgin friend asks you for any advice, tamp down your incredulity, be supportive and tell her the following:

* First-time sex may hurt. It may not. For certain, though, nervousness increases tension, which increases the odds that it will hurt. A glass of wine, a massage, Barry White on the Bose—whatever decreases her anxiety is a good thing.

* A test run may help. She can get used to the idea of something in her vagina ahead of time. Her own finger, a dildo or vibrator, two fingers—accompanied with a lot of lubricant.

* Lube, lube, lube. I can’t stress lubricant enough. No matter how wet she thinks she gets, she’ll find lube makes it easier. It’s not just for sex toys and porn stars anymore.

* Set the stage. This is not the time for a quickie; the more time they can spend together, the better she’ll be able to relax, get wet, and enjoy sex.

* Consider being on top. It’s the position she can best control how fast and at what angle he enters her.

* It’s okay to ask a gyno about it. If she’s really concerned, any good doctor should be happy to talk about these issues; many women may not think about a meeting with their doc before they really get down to business.

* Don’t forget the birth control. We can always get pregnant the first time we have sex, whether we’re 14 or 40.

There are some good resources online, but a lot of baloney as well—it’s all another reason an understanding friend can be indispensable. What would you tell the L. in your life?

I Don't Want Him - But Who DO I Want?

Dr. Kate,

I have only been with one partner, and I've never been abused. My partner is attentive and committed, equally inexperienced but enthusiastically willing to try anything I'm interested in.
Here's the problem: although I started out with very normal desires and expectations, things have really gone south over the course of our three-year relationship, and not in a good way. As far as I can tell, I'm the problem. I hate kissing, especially tongue kissing. I do not enjoy foreplay, although we've read countless books and articles and tried so many different things. I hate cunnilingus; it makes me feel nauseated. I think lingerie is dumb-looking and I feel stupid wearing it, although the idea of him dressing up for me is somewhat appealing. I can climax very easily on my own, but my partner hasn't been able to get me there once. I also don't enjoy cuddling after we have sex. It's the weirdest thing - here is he wanting to linger in the afterglow and share intimate secrets, and I'm the one wanting to roll over and go to sleep. I have a good sex drive and I'm not insecure about my appearance, but for some reason none of the activities we've tried did a thing for me. I always come away frustrated. I'm starting to worry that maybe I'm not straight...I'm from a very religious background and never had the chance to experiment with anything. I don't want to end this relationship because we work together so well on other levels...but I am getting so fed up with our sex life. Any thoughts?

Frustrated

Dear Frustrated,

You're not the problem. Likely neither is he - it may be in the pairing of the two of you. A question: do you ever feel aroused when you're with him? Does a look or a touch from him ever make you tingle or feel turned on or make you want to grab him? If not, it doesn't sound like you're attracted to him. Attraction is different for everyone, but generally leads to some physical feeling in you...if you don't want to kiss him, you simply don't want him.

You say that your sex drive is good - what gets you in gear? Do you get that physical rush from any man? One you know, or one you look at from afar (or even a celebrity)? Is there any fella that you would want to kiss? If not, it's very possible that you're not straight. Have you ever let yourself even think about being with a woman? How do you feel, just thinking about kissing a woman? Give yourself some time to explore thoughts like these. There are many resources out there for you - many are geared towards teens (and you haven't told me your age), but are still really good.

You might want to consider a psychologist or therapist to be able to confidentially talk out how you're feeling. I hope you can at least find a friend to talk to - it's not going to be easy, these next steps. But you're brave to take them - we all deserve to feel physically good with our partner. Your boyfriend sounds wonderful, but he doesn't sound like what you want.

Best of health,
Dr. Kate

The Ultimate User's Guide for the Nuva Ring

When it comes to hormonal birth control, I get more questions about the NuvaRing than any other method (see for yourself here). It just doesn't seem to be as intuitive as the once-a-day-every-day tyranny of the birth control pill. Most women's questions focus on the timing of the ring, and what happens if their schedule gets thrown off. So this is everything you need to know about using the NuvaRing.

1. When to start it. You can start the ring any time you want:

• If you're starting it with your period, put in the ring during the first 5 days of bleeding.
• If you're starting it later than that, or totally off your period, take a pregnancy test first. If negative, begin the ring that day.
• If you're switching to the ring from the pill or patch, you can place the ring on the day you would have started your new pack of pills or box of patches.
  

2. How soon you're protected. It dependes on when you started the ring:

• If you place the ring on the first day of your period, you're protected immediately.
• If you directly switched from the pill or patch to the ring, you're protected immediately.
• If you started the ring at any other time, you need to use condoms for 7 days for maximum contraception protection.

3. How long to leave it in. The ring needs to be in your body for 3 straight weeks. Don't take it out early if you start bleeding early than you expect - the ring needs its three weeks to work. If you remove the ring before the three weeks are up, you're at risk of pregnancy that cycle.

4. How long it can stay in. The ring has enough hormones so that it may be left inside for up to 5 weeks and still be effective. So you've got lots of flexibility in how long the ring is in. And you don't need to use the ring for the same amount of time each cycle - some months you may leave it in 3 weeks, some up to 5 weeks - your body will adjust. But if it's left in longer than five weeks, you're now at risk of pregnancy.

5. How long you can leave it out. The ring cannot be out of your body for more than 7 days - in other words, you need to put a new ring back in by the same day of the week that you removed the old one. This rule holds even if you're still bleeding - the new ring must be reinserted within a week.

6. When it's out, you're protected. If you've used the ring following these guidelines, you're still protected against pregnancy during the ring-free week. The ring has suppressed ovulation for that cycle, so you don't need a back-up method of birth control during the ring-free week (though condoms are always a good idea for infection prevention...).

7. Ring holiday. The exception to rule #3: you can remove the ring for up to 3 hours at a time for sex (or any other reason...) and still be protected against pregnancy. There are no studies that tell us how often you can take a ring holiday; I counsel my patients that they can remove the ring once a day for 3 hours and are likely still safe.

8. If the holiday runs long... If the ring is out of your body for more than 3 hours, it's possible that your ovaries will respond with a quickie ovulation. So put the ring back in and use condoms for a week.

9. If you're late putting a new ring in. If the old ring has been out for more than 7 days, put the new ring in anyway. Don't wait for your period to start (so many women become pregnant while they're waiting!). Then use condoms for 7 days.

10. Back-to-back. You can use a new ring directly after taking out the old one - you don't need to leave a ring out for any length of time, you don't need a back-up method, and you can do this indefinitely (no need to ever bleed).

11. Bleeding patterns. It's normal to have irregular spotting or bleeding during your first few months on a new birth control method. Don't pull the ring out if you begin to bleed early - it doesn't mean the ring is "finished," it's just breakthrough bleeding while your body is adjusting.

12. Other things in your vagina. All okay. Including semen.

13. You can't lose it in your body. As long as the ring is all the way in the vagina, and it feels comfortable, you’re good to go. It doesn’t need to be in a particular place to work, and it won't go in too far.

And one final thought - this should go without saying: If you have sex without using the ring correctly, you are at risk of pregnancy. Take a pregnancy test if your period doesn't come when you expect.

The Birth Control Pill Is So Much More

My new patient J. came into my office with her mother last week, to discuss her awful periods. She's 13, and has been to the emergency room several times (and missed over a week of school this year) because of heavy bleeding and disabling pain. I was excited about offering J. the birth control pill--I don't often have the chance to greatly improve someone's life with a simple prescription. But her mother resisted, because when she was young, "only bad girls went on the Pill that young." Forty-five minutes of conversation later, J.'s mother promised to think about it.
This encounter was a reminder that the birth control pill has a bad name. Sure, it's contraceptive power is fantastic (97% effective when used perfectly). But it's so much more than that:

• The anti-anemia pill. You bleed less heavily and for fewer days each month.
• The anti-cramp pill. You need less ibuprofen...and maybe none at all.
• The pro-clear-skin pill. Dermatologists recommend the pill to help control acne.
• The anti-hair-in-the-wrong-places pill. Meaning less hair growth on your face.
• The cyst-reduction pill. You reduce the chances of benign ovarian and breast cysts.
• The cancer prevention pill. Reduce your risk of ovarian cancer by 50% and your risk of endometrial cancer by 80%.
• The mood stabilizer pill. The pill can work wonders in some women with premenstrual dysphoric disorder (PMDD).
• The bone strengthening pill. Studies indicate that use of the pill can help ward off osteoporosis.
• The pro-fertility pill. The pill provides some protection against pelvic inflammatory disease (PID), a major cause of infertility.

All of these reasons can give you incentive to stay on your pill, even if you don't need the contraceptive benefits any longer.

How Will Her Ring Affect Me?

Dr. Kate,

I'm in a relationship with another woman who because of health issues has been put on a contraceptive device (Nuva Ring - a low estrogen ring thing that she inserts once a month). She has just started this but obviously none of the common questions included in the package address whether or not this will have any effect on a female partner. Any ideas? Thanks!

F

Dear F,

You're right, the package inserts of vaginal products are woefully short of advice for their user's partners, male or female. The Nuva Ring releases a small amount of hormone every day that will be absorbed through your partner's vaginal walls. The ring should have no affect on you during sex - your fingers or tongue are not going to absorb any significant amount of hormone. If you're both uncomfortable with the idea of the ring still inside her when you're intimate, she can take the ring out for up to three hours. She can then put it back in, and shouldn't see any change in her bleeding patterns or other happy-ring effects.

Best of health,
Dr. Kate