The theoretical limit on the number of children a woman can have is sixteen. The record is twenty-seven live births to one woman. The highest rate for a society was an average of twelve children per woman among the Hutterites of Canada in the early twentieth century. That dropped to six by the end of the century. From these numbers it is obvious that throughout history, women have found ways to reduce their fertility – they have practiced some form of conception or birth control.
Documented practices have included avoiding vaginal sex (it is not by coincidence that biblical stories and Egyptian art include withdrawal, anal and oral sex). We know that variants of condoms, intra-uterine devices and chemical potions have been used throughout history. That has not changed; what has changed in the last century is the convenience of regulating pregnancy. Most things available are described in Golden Posts or elsewhere on this site. More information on any form is available through Planned Parenthood or other women’s health sites, your doctor, even your school nurse.
So, you ask, what is best? That, I say, depends. It depends upon your age, sexual activity, marital status, desire for future children, the risk you are willing to live with. The only certain approach is abstention from vaginal sex. There are women with active sex lives who rarely take a penis into their vaginas. Oral, digital and other creative forms of stimulation are used to the exclusion of genital contact. Most of us, while enjoying all these techniques, also want the satisfaction of actually taking a penis into us.
The commercial, convenient approaches can be placed into categories. Barrier methods mechanically prevent sperm from entering our uterus. Chemical methods kill the sperm in our vaginas. Hormonal approaches prevent either ovulation or implantation of the egg in the uterus’ wall. Intra-uterine devices mechanically prevent the egg from implanting itself in the uterine lining. Sterilization stops either the egg or the sperm from the assignation in the fallopian tubes. Some people see the iud and some pills as causing abortion because the fertilization has taken place but the fertilized egg is denied the chance to develop. That interpretation is up to you.
I have personally used all these techniques except the iud. I have recommended or prescribed every one of the approaches. Including, “Don’t!”
The most accessible, economical and convenient is the condom. All the barriers, including condoms, should be used with a spermicide. That is, all the barrier methods are improved by, or require, chemical backup. With the diaphragm or cervical cup, the spermicide is required. The sponge is a barrier that is impregnated with spermicide. Relatively few women continue to use the diaphragm or cervical cap. Some, however, do use the flexible, disposable menstrual cup, filled with vaginal jelly, as a cervical cap. It certainly looks like one, but is deeper. They are not recommended as contraceptive devices and come in only one size. The literature that comes with them does recommend them for use during menstrual sex. Draw your own conclusion, recognizing that there is a possibility that they can be dislodged when a penis gets in there.
The condom plus spermicide is the most common form used by younger women having intermittent sex. When used with added contraception (not just the spermicidal lubricant on them), they are as effective as the pill or other hormonal approaches. This is the approach I recommend most commonly for young women starting their sexual activities. There is no prescription required and both the condoms and various spermicides are easily available. Some women use condoms throughout their lives.
A “recent” addition to the condom is the “female” condom. Actually, the Romans used goat bladders centuries ago as female condoms. The female condom is quite large, has two rings (one inside and one outside the body) and is inserted into the vagina. Spermicide should be placed into the vagina and into the condom. The reason I recommend placing spermicide into condoms (either regular or female) is that most condom failure is not failure of the condom, itself, but leakage around the open end. A bit of spermicide in the condom reduces this risk a bit. Also with the female condom, the penis slides inside the condom and many men feel they are less desensitizing than regular condoms. Lacking a penis, I cannot comment. For the same reason (the penis sliding inside the condom), I find them less realistic. In the vagina, there are no nerve endings, so evidently the friction against my “externals” is somewhat reduced. This will vary among women.
The female condom is comparatively quite expensive. The World Health Organization is presently testing them in some countries for multiple uses. With proper washing and checking, they should work for several uses.
Using spermicides alone is about as effective as using condoms alone. The advantage is that there is no mechanical separation between penis and vaginal wall. If inserted right before the penis, they do not get in the way of oral warm-ups but would require a brief pause for insertion. Spermicides are available as jelly, film, foam or suppository. The jelly and foam require an applicator; the film and suppository a brief wait (longer for the suppository) for the “melting.” While not as effective alone as with a barrier, women for whom pregnancy is not a disaster can take this approach quite conveniently. Perhaps while “coming off” a hormonal system would be an appropriate, temporary use of spermicides alone. Single, young women for whom pregnancy would be more than an inconvenience, should not use spermicides alone. Some couples share the responsibility: the man sometimes uses a condom; the woman, a spermicide.
The sponge is a very popular system combining the barrier (actually, the sponge absorbs the semen) and chemical approaches. The sponge is about as effective as a properly used condom. It is dampened and inserted sometime before the penis. This can be up to hours before or just before – it is immediately effective. Young women for whom pregnancy is highly undesirable may want to use the sponge along with the partner using a condom. For married women, the risks of the sponge alone are probably entirely acceptable.
The most common contraceptives for women in their twenties are hormonal. These are administered as the pill, patch, ring, shot or implant. There are many pills available with different formulations. Most women can find one or another of these systems useful. Often, several must be tried until the ideal is found. A new pill has recently been introduced that reduces menstruation to four periods a year. Which of these systems is chosen is a very individual decision. Each requires prescription and the implant and shot require medical involvement. The patch would have the problems of any adhesive device and the ring should be checked regularly with a finger. If you find the ring among the bed linen, you have a problem. This is not common but is a possibility. During foreplay, the position of the ring can be either checked or adjusted. The biggest advantage of the ring is its very low dosage and it is tolerated by some women who cannot tolerate the other dose rates.
The hormonal systems have very low “failure” rates and represent risks acceptable to most sexually active women. Care must be taken with interactions with other drugs (especially anti-biotics) or dietary supplements. These should be discussed with the doctor prescribing, and other doctors prescribing should be advised what form of birth control you are using.
The intra-uterine device is a surprisingly old and presently under-used approach. For at least 900 years, women on Taiwan have inserted pebbles from a special stream into their uterus. There were problems with one particular iud during the 1980s that have scared many women off. More modern iud’s are very effective and can be tolerated by 95% of all women. The downside is that they require a doctor or nurse to insert and remove them. They have trailing strings to allow you to insure that they are in place. They are nearly as effective as the hormonal systems and are appropriate for most women in their twenties and thirties. For younger women, it is desirable to avoid the hormones and the iud, if you are comfortable asking the doctor, is a very effective backup that your partner may not even be aware of while he continues using condoms.
As women get into their thirties sterilization has become the most common form of contraception. Either the woman has a tubal ligation or her partner has a vasectomy. Choice is up to the couple involved but it always occurs to me that it is the female body that gets pregnant. Enough said. I had my tubes cut when I was thirty. The vasectomy is a simpler, cheaper, lower risk (no general anesthesia) procedure. The ligation protects the body that becomes pregnant. Your choice. Either approach should be considered final. You must be certain that under no circumstances would you want children before you make this decision. Even though there are physicians who specialize and advertise reversal of these procedures, do not count on it. There are infrequent side-effects reported with either procedure and reversing it surgically will not reverse these side effects. They are very rare but should be discussed with the doctor before you make a decision. I have seen none of the side effects in patients I have referred for either of these procedures. About one woman in 10,000 has an unexpected pregnancy after sterilization of either herself or her partner. Newer procedures may be reducing this “healing.”
So, what do I recommend? In my teen aged patients who are sexually active but living at home, I recommend condoms with vaginal jelly. In their late teens, I may suggest an iud while the partner continues to use a condom. In young married women, the recommendation varies. Those who are delaying pregnancy for quite a while should be using an iud or one of the hormonal systems (I prefer the ring for starters). If pregnancy is a matter of convenience and will be wanted in the near future, the sponge or chemical approaches are what I recommend. After all wanted pregnancies are completed, we talk about sterilization, iud or hormonal systems. The decision is theirs.
I still have a few patients using diaphragms because they became comfortable and confident with them and simply do not want to change. One of these women discovered the menstrual cup as a convenient alternative (she went on holiday and forgot her diaphragm) and told me about it. She has been using that for a few years.
The purpose of Chick Chat is exchange of ideas. Bring them on.
(posted on behalf of Brandye by the moderator)