Women’s Health
major birth control methods explained

Everything You Need to Know about All Your Birth Control Options

An informed decision is a good decision.

By: Hannah Hickok
Graphics: Marites Algones

This story is part of Coveteur’s Women’s Health series. For more on this topic, head here.

 

Birth control can be confusing—even for those who have been using it regularly since their teens. But if confusion is the cost of abundant contraceptive options, it’s a price most women will happily pay. Contrary to what some politicians and presidents believe, our reproductive systems are ours to manage. That means keeping abreast of our choices, which are many and varied, thanks to research and a market that’s evolving to meet the changing needs of women today.

“Anecdotally, millennials and early generation Z may be looking for more convenience than a daily pill, and often fewer hormones,” says Dr. Paula Brady, MD, fertility specialist at Columbia University Fertility Center. “I think increasingly women do not want to be constrained by their contraception—by remembering to take it, or by struggling with side effects. Studies also show that more women are delaying childbearing, and long-acting reversible contraception is an effective way to support that plan.”

While birth control methods on the higher-maintenance end of the spectrum (the mini-pill, internal condom, or cervical cap, for instance) might be starting to lose steam, those on the upswing include the progestin shot, progestin implant, and IUDs. The shot lasts for a few months, and the implant and IUDs are effective for years, require minimal upkeep, and are quickly reversible—making them favorites of gynecologists like Dr. Brady.

There are 12 main kinds of contraception to consider, short of options that are permanent (vasectomy or sterilization), emergency-specific (morning-after pill), or lifestyle-related (abstinence, pulling out, breastfeeding, or the rhythm method). Ahead, get a clear, up-to-date breakdown of the major birth control methods sexually active women should know about.

 

The pill

 

How it works

Daily oral prescription contraceptive pills work by strategically releasing hormones to make your body pregnancy-unfriendly—in other words, temporarily and artificially infertile. “Birth control pills have long been the workhorse of contraception,” says Dr. Brady. “Easily available and appropriate for use in most patients, the pill is still the most utilized form of birth control.”

When taken right, the pill releases synthetic hormones that mimic the ones your body makes naturally, which add barriers to each stage of the reproductive process, making egg fertilization all but impossible. Progestin acts like progesterone in order to curb ovulation (egg release), thins your uterine lining (making it harder for an egg to implant, if one is released), and thickens your cervical mucus (blocking sperm from reaching the egg, if one does implant). Estrogen’s functions are fewer, but still important—it helps prevent ovulation and reinforces the uterine lining to prevent breakthrough bleeding. There are dozens of different brands that make their own versions of the pill, which typically costs less than $50 per pack, based on your insurance. Women can choose from two types: combination pills, with both progestin and estrogen; and the progestin-only mini-pill.

 

About the combination pill

Combination pills can be broken down into two subcategories. Conventional combination pills facilitate monthly bleeding via a few weeks of active (hormone-releasing) pills and a few days of inactive pills, aka placebo or sugar pills, which trigger your “period.” (The bleeding you experience on the pill isn’t technically menstruation, since you haven’t ovulated—it’s withdrawal bleeding, resulting from the drop in hormones from inactive pills.) Extended cycle combination pills reduce the frequency of bleeding by upping the length of active pill intake to 12 consecutive weeks, punctuated by a week of inactive pills four times a year.

 

Is the combination pill for you?

The benefits of combination pills are plenty, including lower risk of ovarian and endometrial cancers; milder cramps and PMS; and a possible boost to bone mineral density. “It also has the added benefit of clearing up acne for many patients, which is not generally true of progestin-only or non-hormonal contraceptives,” says Dr. Brady.

But the downsides, too, should be seriously considered: Heightened risk of heart attack, stroke, and blood clotting, and side effects such as depression, weight gain, headache, bloating, and nausea. Smokers should avoid combination pills due to estrogen’s link to lung cancer (or just quit smoking). And, of course, since the pill provides no physical barrier during intercourse, it doesn’t protect against sexually transmitted infections.

 

About the mini-pill

The mechanics of the mini-pill are simpler than combination pills, since it only includes one hormone, progestin, and comes in a single formula—28 days of active pills. Bleeding on the mini-pill can be unpredictable: Some women never experience it; others spot throughout the month. Because it only contains one hormone at a relatively low dose, it can work well for women looking for a low-impact form of birth control.

 

Is the mini-pill for you?

Perks of the mini-pill include the ability to take it while breastfeeding, as a smoker, or if you have health issues such as heart disease, blood clots, high blood pressure, or migraines. It also allows for a near-immediate return to fertility when you go off it. The mini-pill comes without certain risks that have been associated with estrogen intake (heart attack, blood clots, and stroke, as mentioned above).

On the other hand, the mini-pill doesn’t prevent acne, and is significantly less effective when it’s not taken precisely as specified. “The mini-pill is overall less utilized, as patients have to take it at the exact same time every day for efficacy, which is challenging,” says Dr. Brady, adding that there are plenty of other progestin-only options for women who prefer to avoid estrogen, including the implant, shot, and hormonal IUDs.

 

The ring

 

How it works

The ring is a prescription, non-toxic plastic ring about two inches in diameter that is inserted into the vagina, where it releases a combination of estrogen and progestin into the vaginal lining. The hormones block sperm from entering the uterus by thickening cervical mucus and prevent ovulation, so there’s no egg to fertilize. You insert the ring, which is currently made by a brand called NuvaRing, manually into your vagina every month, and remove it by hooking your index finger around it and pulling it back out.

 

Is it for you?

One great aspect of the ring is that you can control whether you get your period, and how often, by timing its insertion and removal. It’s safe to keep in during sex and while wearing tampons during your period. It typically costs less than $200 and is about as effective as the pill, with protection varying from 92 to 99.7 percent based on correctly replacing the ring each month.

The most common side effects of the ring are vaginal infections, nausea, headaches, and spotting. Rarer but more serious ones include elevated blood pressure, migraines, gallbladder issues, benign liver tumors, risk of blood clots, heart attack, and/or stroke.

 

The patch

 

How it works

The prescription contraceptive patch is a palm-sized beige plastic adhesive that releases the sperm- and ovulation-thwarting combo of estrogen and progestin into your skin. It’s worn on the stomach, upper arm, back, or butt; it costs less than $150, and has to be changed three times a month. When done right, it’s 91 percent effective.

 

Is it for you?

Xulane, the generic brand of patch currently available, only comes in beige—groan—so isn’t ideal for darker-skinned women seeking invisible birth control. Because of its estrogen content, it comes with a risk of blood clots, heart attack, and stroke, along with breakthrough bleeding, tender breasts, and headaches.

For those who aren’t put off by the side effects or short-sighted color palette, the patch has unique benefits: It can prevent bone thinning, breast and ovary cysts, ectopic pregnancy, endometrial and ovarian cancers, anemia, reproductive organ infections, acne, PMS, and cramps.

 

The implant

 

How it works

The birth control implant is a matchstick-sized rod made of nontoxic plastic that, like hormonal IUDs, prevents pregnancy by releasing progestin to block sperm and curb ovulation. It’s inserted into the skin of your upper arm after a numbing shot, which tends to sting briefly, then ache and bruise for about a week until the skin has healed.

 

Is it for you?

Like IUDs, implants require no maintenance and are usually not visible in the arm. They offer 99 percent protection, can reduce cramps and lighten (or stop) periods, and are fully reversible. Downsides include spotting, and, less commonly, headaches, nausea, weight gain, and ovarian cysts. Nexplanon, the brand currently on the market (Implanon is an older version), can cost up to $1,300 and lasts up to five years.

 

The shot

 

How it works

Like the mini-pill, hormonal IUD, and the implant, the birth control shot uses progestin to prevent pregnancy by inhibiting the body’s ability to release an egg and fertilize it. Manufactured under the name Depo-Provera (nicknamed Depo), the injection is administered every three months by a doctor or nurse, or, in some cases, you can give yourself prescribed shots at home.

 

Is it for you?

The Depo shot typically costs less than $120 and is about 94 percent effective. It can lighten or stop periods and help protect against uterine cancer and ectopic pregnancy. However, when you stop receiving shots, there can be a delay of nine to 10 months before you can get pregnant. It can also cause nausea, weight gain, headaches, breast tenderness, depression, and (rarely) a small permanent dent in the skin from the shot.

 

The IUD

 

How it works

Intrauterine devices (IUDs) are tiny T-shaped gadgets that are inserted into the uterus to prevent sperm from fertilizing an egg. “There is a lot of misplaced distrust of IUDs due to complications from decades ago with specific IUDs that are no longer on the market,” says Dr. Brady. “Gynecologists and pediatricians were long reticent to place IUDs in very young women, but in 2014 the American Academy of Pediatrics endorsed IUDs alongside progestin implants as the most effective contraceptives and recommended in teens. Women in their 20s and 30s use IUDs the most compared to other age groups.”

IUD users can choose from two types: hormonal and copper. Both are manually inserted into the vagina in a non-surgical procedure that typically takes less than five minutes. It’s normal to experience some cramping, pain, and spotting after insertion. IUDs fall into the long-acting contraception (LARC) category and can cost up to $1,300 based on your insurance. They can be pricey, yes, but last between three to 12 years, and can be removed anytime by a health-care pro pulling a short string extending from the cervix into the vagina.

 

About hormonal IUDs

Hormonal IUDs are made of flexible plastic and release progestin, which thickens cervical mucus in order to block sperm from entering the uterus, and can also inhibit ovulation. There are four brands of hormonal IUDs currently on the American market: Mirena (which can last up to seven years); Liletta (seven years); Kyleena (five years); and Skyla (three years). “The expanded offering indicates growing acceptance of the IUD and allows physicians to tailor IUD selection—size, dose, duration—to patients’ preferences and needs,” says Dr. Brady. “The Liletta is marketed as a less expensive alternative to the the classic progestin IUD, Mirena; the Kyleena offers a lower dose of progestin; and the Skyla has a low dose of a progestin and [has a] smaller inserter, so it may be more comfortable for women who have never had a baby.”

 

About copper IUDs

Copper IUDs cause a controlled amount of inflammation in the uterus, triggering the immune system to release sperm-killing white blood cells. Copper ions also change the properties of cervical mucus, giving it spermicidal abilities and making it harder for sperm to penetrate the cervix. There’s only one brand of copper IUD, the ParaGard, which lasts up to 12 years.

 

Is the hormonal or copper IUD for you?

Both types of IUDs are favorites of gynecologists, as they’re more than 99 percent effective and don’t require daily action from patients. IUDs also provide long-term protection, and are fully reversible, with zero impact on fertility. Hormonal IUDs have the added benefit of reducing cramps or lightening periods. The copper IUD is hormone-free for those who don’t want to take progestin or estrogen—plus, it’s versatile and can be inserted within five days of unprotected sex as a form of emergency contraception.

Negative side effects of IUDs are rarely serious and tend to improve within a few months, but they can include spotting, irregular periods, aggravated cramps, and backaches. Like all non-condom forms of birth control, IUDs do not protect against STIs.

 

The condom

 

How it works

Odds are you’re familiar with the traditional male condom: It’s a pouch that covers the penis during sex to prevent pregnancy and STIs. Condoms are made of various materials, including latex (the cheapest and most popular); polyisoprene (synthetic material with a soft feel); polyurethane (stronger and thinner than other materials), or lambskin (literally sheep intestines). Condoms should be put on an erect penis before it comes into contact with a partner’s mouth or genitals. They’re best used with lube that’s silicone- or water-based, versus oil, which can break condoms not made of polyurethane.

 

Is it for you?

Condoms are disposable, easy to come by, and affordable ($2 or less), with an 85 percent rate of effectiveness. Aside from rare cases of irritation, they have essentially no negative side effects. It’s smart to combine condoms with other methods like the pill, ring, shot, implant, or IUD. That way, you’re physically protected from exposure to STIs as well as pregnancy—and you have backup birth control if one method fails.

 

The internal condom

 

How it works

Internal condoms are sheaths made of a synthetic, hypoallergenic rubber called nitrile that are inserted into the vagina to create a physical barrier between sperm and the uterus. (Once known as female condoms, the name was changed since they can also be used for anal sex among all genders.) When used correctly, the internal condom is 79 percent effective in preventing pregnancy and is also a good means of protecting against STIs. They’re disposable, single-use, and typically cost less than $5 apiece. It’s crucial to only wear one condom at a time—never combining an internal condom with an external one—which can create friction and risk a tear.

 

Is it for you?

One major advantage of the internal condom is that it gives women more control than when condom use is entrusted to a male partner. You can ensure it’s used properly—with lube, if you want, but never with spermicide—and in time (up to eight hours before sex). Some users may actually experience enhanced stimulation as a result of the condom’s shape: The outer ring rubs against the clitoris, while the inner ring can stimulate the head of the penis. Downsides can include irritation and the inconvenience of interrupting sex in the moment. Internal condoms can also be a bit trickier to find than male condoms, but are available online, in health clinics, and by prescription in pharmacies.

 

Spermicide

 

How it works

Spermicide is an over-the-counter cream, gel, film, foam, or suppository that contains an active chemical—most commonly nonoxynol-9, or N-9—that stops sperm from reaching an egg. It doesn’t technically kill sperm, but it does block the entrance to your cervix and slow down sperm so that it can’t access your uterus. It can be inserted into the vagina solo or in tandem with other methods (a diaphragm, cervical cap, or sponge—see below). Several brands make spermicide, and various kinds work differently: Some must be applied 10 to 15 minutes before intercourse; some are null after an hour, so reading the directions is key.

 

Is it for you?

Spermicide is cheap (typically no more than $8), easy to find, and hormone-free. However, N-9 can irritate genital tissue when used frequently, upping your odds of infection, and therefore your vulnerability to STIs. It can be less than sexy (messy and gross-tasting—though it’s harmless to consume). Most importantly, spermicide is only 71 percent effective, making it even more crucial to combine it with other birth control methods.

 

The diaphragm

 

How it works

The diaphragm is a soft, saucer-like silicone cup that you manually insert into the vagina before sex to cover your cervix and stop sperm from entering the uterus. Diaphragms are sold by two brands, Caya and Milex, cost less than $90, and come in several different sizes. Your doctor will fit you and give you a prescription for the right one. They’re most effective when you add a tablespoon of spermicide into the cup before inserting it less than two hours before sex. It should stay in your vagina for at least six hours after sex, but no more than 24. When these rules are followed, diaphragms are 88 percent effective and can last for up to two years with proper cleaning and storage.

 

Is it for you?

Diaphragms are hormone-free, eco-friendly, and won’t hinder pleasure during sex (most people and their partners can’t even feel them). However, they have a number of limitations. You shouldn’t use them if you have a sensitivity to silicone or spermicide; if you gave birth or had a second- or third-trimester abortion within the last six weeks; if you’ve had toxic shock syndrome; if you or your partner have HIV or AIDS. They can also be displaced and, since they’re used with spermicide, can increase your risk of urinary tract infections or STIs.

 

The cervical cap

 

How it works

Cervical caps are much like diaphragms—a soft silicone cup manually inserted to cover your cervix, used with spermicide. The key differences: They’re smaller than diaphragms, so require less spermicide; they can be left in longer (up to two days); and have a different shape, so have to be inserted accordingly. Your doctor will help determine which of the three sizes of FemCap, the brand available in the U.S., is right for you.

 

Is it for you?

Cervical caps have the same pros and cons as diaphragms, but they’re slightly less effective, with a 71 to 86 percent protection rate. They typically cost less than $90 and last half as long as diaphragms, requiring replacement each year.

 

The sponge

 

How it works

The contraceptive sponge works similarly to diaphragms and cervical caps, except that it’s made of squishy fabric shaped like a mini-donut with a sunken center instead of a hole. Instead of adding spermicide yourself, the sponge contains spermicide that is activated when you rinse it with water. Inserted like a tampon, it can be put in up to 24 hours before sex, must remain inside you for six hours after sex, and is effective for 24 hours after insertion. The sponge, sold under the name Today Sponge, cannot be reused.

 

Is it for you?

The sponge is estimated to be 76 to 88 percent effective. Sold over-the-counter at $15 for a pack of three, the sponge is easy to access and keep on you, much like a tampon. It’s hormone-free—a plus—but not the most environmentally friendly, since it’s disposable. It’s recommended that you combine the sponge with a condom to optimize protection from both pregnancy and STIs. Like any birth control method involving spermicide, users are at risk of irritation and infection. The sponge also ups your risk of toxic shock syndrome, and can be messy or cause vaginal dryness (which can be mitigated with lube).

 

[Editor’s Note: As ever, we are not doctors or medical know-it-alls. And everybody is different, so make sure to check with a doctor before trying anything new.]

 

Want more stories like this?

Is the Pill Actually Healthy?
What to Expect When Going Off the Birth Control Pill
Everything You Need to Know About IUD Birth Control

×