Birth control – whose choice? June 3, 2013 –

Ask a woman if she is using birth control and she will likely tell you whether or not she is taking “the pill.” For most women, they are synonymous. Often, she’ll ask her doctor to “put” her on the birth control pill, which conjures the image of a five-minute consultation, prescription pad at the ready. Do the words “informed consent” have any real meaning when it comes to birth control?

Women who need birth control are likely to change methods several times during their reproductive years depending on their age, health status, income, partner(s) and number of children. Knowing those circumstances is key to assisting a woman in finding the method that suits her at that particular time in her life. While health-care providers may have prejudices and biases regarding certain methods, the operative word should always be “choice”: hers.

Oral contraceptives (the pill) are clearly the method of choice for most health practitioners because of the effectiveness when used as prescribed. The copper IUD (intrauterine device) is nearly as effective; but it is only recently that health-care providers changed their prescribing practices due to its updated safety record, resulting in increased use, including for women who have never been pregnant. The cheaper, non hormonal IUD is often overlooked by health-care providers in favour of the Mirena Intra Uterine System (IUS), an IUD that releases a progestin. It was originally designed to help women with very heavy bleeding, but it soon became commonly prescribed, possibly due to aggressive marketing. A woman on social assistance in some provinces, like Ontario, is more likely to use Mirena than the copper IUD, even if she prefers a non-hormonal method, because she has to pay for the copper IUD whereas Mirena is covered by the government. This is illogical and wasteful, as the Mirena actually costs about four times more than the IUD (when obtained in publicly funded clinics); it is usually more expensive when inserted by a family doctor.

A woman who wants to use a combined hormonal method, but does not want to take a daily pill may opt for the patch or vaginal ring. The patch has a higher dose of hormones; the vaginal ring uses a “third generation” progestin (see below). Her remaining hormonal option is Depo Provera, a method that should include comprehensive counselling about potential side effects.

Otherwise, she can use condoms (male or female), withdrawal, Natural Family Planning or a combination. She is unlikely to find a clinic that still carries the diaphragm or the gel that accompanies it.

Teaching a woman the basics of her menstrual cycle—in particular, recognizing fertile mucus with a view to charting her fertile days—is a fundamental strategy in educating women about their bodies. There’s even an app for that. If she wants to use this knowledge to prevent pregnancy, she can use the Standard Days Method.

Understanding fertility can also increase the effectiveness of a method like withdrawal, which has a “perfect use” effectiveness rate of 96 per cent. Granted, with typical use, it drops to 73 per cent. If there’s a slip-up, she can take emergency contraceptive pills (or use a post-coital IUD). Although Plan B does not have a consistently high effectiveness rate, its availability over the counter has increased access.

With regard to hormonal methods, there are safety issues which may not be raised by health-care providers.

Women who were already taking pills often wanted to buy them more cheaply from the sexual health clinic where I worked. Some had been prescribed Diane-35 by their doctor. This medication, which is  only approved for short-term use to treat serious acne and hirsutism, also has contraceptive properties. Pharmaceutical companies highlighted the latter application to doctors. So, although it has never been approved as a contraceptive, it is prescribed “off-label” as birth control. When women asked me about Diane-35, I directed them to the Health Canada website and warning because women using Diane-35 as birth control are likely not aware that its use as a contraceptive is off-label. Diane-35 is no longer prescribed in France because of four thrombosis related deaths, and Health Canada recently reminded prescribers ”that Diane-35 should not be used as an oral contraceptive.”

Third and fourth generation birth control pills contain progestins that are associated with a higher risk of blood clots. The brand name drugs Yasmin and Yaz are currently named in lawsuits because of safety issues with the progestin, drospirenone. The vaginal ring uses a third generation progestin, desogesterel. Is there any discussion of that fact before a woman receives her prescription? Mea culpa: I never mentioned it.

Continuous oral contraceptives were first marketed to women by asking them if they wanted to have fewer periods, presumably with the intention of “liberating” them from this bodily function. Many women did switch to continuous oral contraceptives; however, I am unaware of any research into potential long-term consequences (for example to their breast health) of an increase in estrogen over the long term.

Health-care providers are charged with giving patients clear and up-to-date information so that they can make informed choices. Patients must demand nothing less.

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