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Female Contraception

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Iqra Mazhar

Overview

Contraception, also known as birth control, refers to the methods, devices, or techniques used to prevent pregnancy. Female contraception includes birth control methods employed by women.

Birth control methods can be dated back as far as the 1850 BC to Ancient Egypt where they used various plants as contraceptives. Modern-day contraception has evolved far beyond herbal concoctions, providing women with more effective and safer alternatives. Today, women can choose from a wide variety of methods and devices, based on their preferences, medical history, and desire to have children. 
&nbsp;

Importance Of Female Contraception

According to the World Health Organization (WHO), approximately 1.1 billion women of reproductive age required family planning in 2019<a href="#accordion">[1]</a>. Out of these, only 842 million used contraceptive methods, while the rest had an unmet need for contraception<a href="#accordion">[1]</a>.

Contraception methods are vital for not only preventing unwanted pregnancies but also protecting against sexually transmitted infections (STIs). By preventing unwanted pregnancies, women can pursue their education and career goals, and contribute to the workforce. Thus, reducing gender disparities. Moreover, effective use of female contraception empowers women to make informed decisions about their reproductive health and plan pregnancies according to their desires. 
&nbsp;

In Pakistan, contraception is often a sensitive topic, owing to the stigmas and misconceptions surrounding it. Traditional cultural and social norms in Pakistan often place restrictions on discussions around sexuality and contraception. These norms can create barriers to accessing information, seeking contraceptive services, and openly discussing contraception within families and communities. Religious and cultural disapproval is a major cause of women avoiding the use of contraception. Moreover, many women and girls in Pakistan have limited access to comprehensive sexual and reproductive health education, which hampers their understanding of contraception options and how to use them effectively<a href="#accordion">[2]</a>.

Despite being the fifth most populous country in the world, Pakistan has the lowest contraceptive prevalence rate (CPR) across South Asia<a href="#accordion">[3]</a>. The country&rsquo;s CPR has remained at a stagnant 30-35% for quite a while<a href="#accordion">[4]</a>. The national target is to reach 50% CPR by 2025<a href="#accordion">[4]</a>. However, access to contraceptive methods, costs, social barriers, and religious and cultural misconceptions act as barriers to contraceptive use in the country<a href="#accordion">[3]</a>. 
 
&nbsp;

There are several different types of female contraception available. These include<a href="#accordion">[5]</a>: 
&nbsp;

Hormonal Methods

<ul>
	<li>Birth Control Pills</li>
	<li>Birth Control Patch</li>
	<li>Birth Control Injection</li>
	<li>Vaginal Ring 
	&nbsp;</li>
</ul>

Barrier Methods

<ul>
	<li>Diaphragm</li>
	<li>Cervical Cap</li>
	<li>Female Condom 
	&nbsp;</li>
</ul>

Intrauterine Devices (IUDs)

<ul>
	<li>Hormonal IUD</li>
	<li>Copper IUD 
	&nbsp;</li>
</ul>

Emergency Contraception

<ul>
	<li>Emergency Contraceptive Pills: Also known as the &quot;morning-after pill,&quot; taken within a few days after unprotected intercourse to prevent pregnancy. 
	&nbsp;</li>
</ul>

Sterilization Procedures

<ul>
	<li>Tubal Ligation</li>
	<li>Bilateral Salpingectomy 
	&nbsp;</li>
</ul>

Fertility Awareness-Based Methods

<ul>
	<li>Tracking menstrual cycles, basal body temperature, and cervical mucus to identify fertile and infertile days for pregnancy prevention. 
	&nbsp;</li>
</ul>

Lactational Amenorrhea Method (LAM)

<ul>
	<li>This method is typically used by women who have recently had a baby and are breastfeeding. It is a temporary method of birth control. 
	&nbsp;</li>
</ul>

In Pakistan, male condoms and female sterilization are the most commonly used modern contraceptive methods among women<a href="#accordion">[3]</a>. 
&nbsp;

<ol>
	<li>Birth Control Pills - Oral contraceptive pills contain synthetic hormones (estrogen and/or progestin) that prevent ovulation, thicken cervical mucus to impede sperm movement, and thin the uterine lining to hinder implantation.</li>
</ol>

<ul>
	<li>Contraindications: History of blood clots, certain cancers, liver disease, uncontrolled high blood pressure, and certain cardiovascular conditions.</li>
	<li>Side Effects: Nausea, breast tenderness, irregular bleeding, mood changes, headaches, and weight changes.</li>
	<li>Pros: Highly effective when taken correctly, can provide non-contraceptive benefits like improved menstrual cycle regularity and reduced risk of certain cancers.</li>
	<li>Cons: Requires daily adherence, and does not protect against STIs. 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>Birth Control Patch - The birth control patch is a small adhesive patch worn on the skin that releases synthetic hormones (estrogen and progestin) into the bloodstream, preventing ovulation and altering cervical mucus to impede sperm.</li>
</ol>

<ul>
	<li>Contraindications: Same as birth control pills.</li>
	<li>Side Effects: Skin irritation at the patch site, breast tenderness, headaches, mood changes, changes in menstrual flow, and weight changes.</li>
	<li>Pros: Easy to use, only requires weekly application, non-contraceptive benefits similar to birth control pills.</li>
	<li>Cons: Does not protect against STIs. 
	&nbsp;</li>
</ul>

<ol start="3">
	<li>Birth Control Injection (Depo-Provera) - Depo-Provera is a hormonal injection administered every few months, containing progestin that suppresses ovulation, thickens cervical mucus, and thins the uterine lining.</li>
</ol>

<ul>
	<li>Contraindications: Same as birth control pills.</li>
	<li>Side Effects: Irregular bleeding, weight gain, breast tenderness, headaches, mood changes.</li>
	<li>Pros: Highly effective with long-lasting protection (injections every few months), does not require daily adherence.</li>
	<li>Cons: May cause irregular bleeding or spotting, potential delay in return to fertility after discontinuation, does not protect against STIs. 
	&nbsp;</li>
</ul>

<ol start="4">
	<li>Vaginal Ring - The vaginal ring is a flexible ring inserted into the vagina that releases synthetic hormones (estrogen and progestin) to prevent ovulation and alter cervical mucus to impede sperm. It has similar side effects to birth control pills.</li>
</ol>

<ul>
	<li>Contraindications: Same as birth control pills.</li>
	<li>Side Effects: Vaginal discomfort, headaches, nausea, breast tenderness, mood changes, changes in menstrual flow, weight changes.</li>
	<li>Pros: Easy to use, only requires monthly insertion, non-contraceptive benefits similar to birth control pills.</li>
	<li>Cons: Does not protect against STIs. 
	&nbsp;</li>
</ul>

It&#39;s important to remember that individual responses and side effects can vary, and not all women will experience the same side effects. 
&nbsp;

Barrier Methods

<ol>
	<li>Diaphragm or Cervical Cap- A diaphragm is a dome-shaped device made of silicone or latex that is inserted into the vagina to cover the cervix. A cervical cap is similar to a diaphragm and is smaller in size. They both act as a physical barrier, preventing sperm from entering the uterus. Spermicides are often used in combination with the diaphragm or cervical cap.</li>
</ol>

<ul>
	<li>Contraindications: Allergy to latex or spermicide, certain uterine abnormalities.</li>
	<li>Side Effects: Allergic reactions or irritation, discomfort during insertion or use.</li>
	<li>Pros: Reusable, hormone-free, can be used as needed, some protection against STIs.</li>
	<li>Cons: Requires correct insertion and fitting, may increase the risk of urinary tract infections, and spermicides may cause vaginal irritation.</li>
</ul>

&nbsp;

<ol start="2">
	<li>Female Condom - A female condom is a soft, loose-fitting pouch made of polyurethane or nitrile that is inserted into the vagina before sex. It lines the vaginal walls, creating a physical barrier to prevent sperm from entering the cervix.</li>
</ol>

<ul>
	<li>Contraindications: None.</li>
	<li>Side Effects: Allergic reactions or irritation.</li>
	<li>Pros: Provides some protection against STIs, can be inserted in advance, hormone-free.</li>
	<li>Cons: May reduce sensitivity during intercourse, requires correct insertion, may slip or become dislodged. 
	&nbsp;</li>
</ul>

<ol start="3">
	<li>Spermicide - &nbsp;Spermicides are substances, such as creams, gels, foams, or suppositories, that contain chemicals to immobilize or kill sperm. They are used alone or in conjunction with other barrier methods, such as diaphragms or cervical caps.</li>
</ol>

<ul>
	<li>Contraindications: Allergy or sensitivity to spermicide or any of its components.</li>
	<li>Side Effects: Some women may experience allergic reactions or irritation to spermicide products. Frequent use of spermicides may cause vaginal dryness or irritation, and there is a small risk of urinary tract infections or an increased risk of bladder infections.</li>
	<li>Pros: Convenient, non-hormonal, and can be used in combination with other methods to increase effectiveness.</li>
	<li>Cons: Requires frequent reapplication, provides minimal protection against STIs, and has a high failure rate when used alone. 
	&nbsp;</li>
</ul>

It&#39;s important to note that barrier contraceptives provide some protection against sexually transmitted infections (STIs) when used consistently and correctly. However, they may have higher failure rates compared to hormonal or long-acting reversible contraceptive methods. 
&nbsp;

1. Hormonal IUD - A hormonal IUD is a T-shaped device made of plastic that is inserted into the uterus by a healthcare provider. It releases a synthetic progestin hormone locally, which thickens cervical mucus, inhibits sperm movement, and thins the uterine lining to prevent fertilization and implantation.

<ul>
	<li>Contraindications: Pregnancy, certain cancers, certain uterine abnormalities.</li>
	<li>Side Effects: Irregular bleeding or spotting, cramping, headaches, breast tenderness, mood changes.</li>
	<li>Pros: Highly effective with long-lasting protection (3-5 years), reduced menstrual bleeding or no periods, and can be used as a form of emergency contraception.</li>
	<li>Cons: Requires healthcare provider insertion, does not protect against STIs.</li>
</ul>

 
&nbsp;

2. Copper IUD - A copper IUD is a T-shaped device made of plastic with a copper coil that is inserted into the uterus. The copper creates an environment toxic to sperm, preventing fertilization.

<ul>
	<li>Contraindications: Pregnancy, copper allergy, certain uterine abnormalities.</li>
	<li>Side Effects: Heavier, longer, or more painful periods, cramping.</li>
	<li>Pros: Highly effective with long-lasting protection (10 years), hormone-free.</li>
	<li>Cons: Requires healthcare provider insertion, may cause increased menstrual bleeding or cramping, does not protect against STIs. 
	&nbsp;</li>
</ul>

Note: It&#39;s important to note that while IUDs are highly effective forms of contraception, they do not protect against sexually transmitted infections (STIs). Additionally, individual responses and side effects can vary.

&nbsp;

Female sterilization procedures are permanent methods of contraception that involve blocking or sealing the fallopian tubes, preventing the eggs from reaching the uterus, and being fertilized.

&nbsp;

<ol>
	<li>Tubal Ligation - Tubal ligation, also known as &quot;getting your tubes tied,&quot; is a surgical procedure where the fallopian tubes are either cut, sealed, or blocked. This prevents the sperm from reaching the eggs and the fertilized eggs from traveling to the uterus. It can be performed using different techniques, including laparoscopy (through small incisions) or mini-laparotomy (through a larger incision). The procedure is typically done under general anesthesia or local anesthesia with sedation.</li>
</ol>

<ul>
	<li>Contraindications: None, but it is considered a permanent method and should only be chosen by individuals who are certain they do not want to have any or any more children.</li>
	<li>Side Effects: Temporary pain or soreness at the incision sites, potential risks associated with surgery.</li>
	<li>Pros: Permanent contraception, no need for ongoing contraception.</li>
	<li>Cons: Requires surgical procedure, does not protect against STIs. 
	&nbsp;</li>
</ul>

<ol start="2">
	<li>Bilateral Salpingectomy - Bilateral salpingectomy is a surgical procedure where both fallopian tubes are completely removed. Without fallopian tubes, eggs cannot reach the uterus, and sperm cannot fertilize the eggs. It is typically performed laparoscopically, using small incisions, but can also be done during a cesarean section or open abdominal surgery.</li>
</ol>

<ul>
	<li>Contraindications: None, but it is considered a permanent method and should only be chosen by individuals who are certain they do not want to have any or any more children.</li>
	<li>Side Effects: Temporary pain or soreness at the incision sites, potential risks associated with surgery.</li>
	<li>Pros: Permanent contraception, reduces the risk of ovarian cancer.</li>
	<li>Cons: Requires surgical procedure, does not protect against STIs. 
	&nbsp;</li>
</ul>

It&#39;s important to note that both tubal ligation and bilateral salpingectomy are considered permanent methods of contraception and are not easily reversible. They should only be chosen by individuals who are certain they do not want to have any or any more children. 
&nbsp;

Emergency Contraception

Emergency contraception, also known as the &quot;morning-after pill,&quot; is a method used to prevent pregnancy after unprotected intercourse or contraceptive failure.

Emergency contraceptive pills contain synthetic hormones (either levonorgestrel or ulipristal acetate) that work by preventing or delaying ovulation, inhibiting fertilization, or interfering with the implantation of a fertilized egg. They are most effective when taken as soon as possible after unprotected intercourse, preferably within 72 hours (levonorgestrel pills) or up to 120 hours (ulipristal acetate pills).

Common side effects may include nausea, vomiting, fatigue, breast tenderness, headache, and changes in menstrual bleeding. These side effects are generally mild and temporary.

It&#39;s important to note that emergency contraception is not intended as a regular form of contraception and should only be used in emergencies. It does not protect against sexually transmitted infections (STIs) and is not as effective as regular contraceptive methods when used consistently.

&nbsp;

Note: It&#39;s recommended to consult with a healthcare provider to discuss the specific emergency contraception options available, their proper usage, and any potential side effects. 
&nbsp;

The lactational amenorrhea method (LAM) is a natural form of contraception that can be used by breastfeeding women. It relies on the natural physiological changes that occur during breastfeeding. Breastfeeding triggers the release of the hormone prolactin, which suppresses ovulation and prevents the return of regular menstrual cycles.

LAM is most effective when certain criteria, known as the LAM criteria, are met. These criteria include exclusive breastfeeding (no formula or solid foods) on demand, day and night, with no longer than a 4-hour gap between feedings during the day and a 6-hour gap at night. Menstrual periods should not have resumed, and the baby should be less than six months old.

As breastfeeding patterns change, the effectiveness of LAM decreases. If the criteria are not met, or if the woman&#39;s menstrual periods resume, an additional form of contraception should be used to prevent pregnancy. 
&nbsp;

<ul>
	<li>Pros: When the LAM criteria are followed correctly, LAM can be a highly effective method of contraception during the first six months after childbirth, with a failure rate of less than 2% when used correctly.</li>
	<li>Cons: It&#39;s important to note that LAM is a temporary method of contraception and 
	should only be relied upon if the criteria are met and followed consistently. It does not protect against sexually transmitted infections (STIs). If a woman wishes to use contraception beyond the LAM period or if the LAM criteria are not met, it is advisable to consult with a healthcare provider to discuss other suitable contraceptive options. 
	&nbsp;</li>
</ul>

Fertility awareness-based methods (FABMs) of contraception involve tracking and interpreting fertility signs to determine the fertile and infertile phases of the menstrual cycle. 
&nbsp;

<ol>
	<li>Basal Body Temperature (BBT) Method - This method involves tracking the body&#39;s basal temperature, which rises slightly after ovulation due to the release of progesterone. By recording daily temperatures, women can identify their fertile windows and avoid unprotected intercourse during that time.</li>
	<li>Cervical Mucus Method - This method involves observing changes in cervical mucus consistency throughout the menstrual cycle. Fertile mucus, which resembles raw egg whites, indicates the fertile window, while less fertile or non-fertile mucus suggests a lower chance of conception.</li>
	<li>Symptothermal Method - The symptothermal method combines the tracking of basal body temperature, cervical mucus, and other fertility signs (such as changes in the cervix) to identify the fertile window accurately.</li>
	<li>Standard Days Method - The standard days&#39; method is based on the understanding that women with regular menstrual cycles between 26 and 32 days are likely to be fertile between days 8 and 19 of their cycle. During this period, couples either avoid intercourse or use additional barrier methods. 
	&nbsp;</li>
</ol>

Fertility awareness-based methods require education, understanding of fertility signs, and consistent tracking to be effective. They are most suitable for individuals who have regular menstrual cycles and are committed to monitoring and interpreting fertility signs accurately. 
&nbsp;

Note: It&#39;s important to consult with a healthcare provider or a certified fertility awareness educator to learn the methods correctly and to discuss any specific considerations or side effects related to these methods.

&nbsp;

Key Points

<ul>
	<li>Female contraception, also known as birth control, refers to methods used by women to prevent pregnancy.</li>
	<li>The primary goal of female contraception is to allow women to have control over their reproductive choices and prevent unwanted pregnancies.</li>
	<li>Female contraception includes various methods such as hormonal regulation, physical barriers, and intrauterine devices (IUDs).</li>
	<li>Options like birth control pills, patches, injections, and vaginal rings use synthetic hormones to prevent ovulation, thicken cervical mucus, and thin the uterine lining.</li>
	<li>Diaphragms, cervical caps, and female condoms create a physical barrier to prevent sperm from reaching the cervix.</li>
	<li>Intrauterine Devices (IUDs) are T-shaped devices inserted into the uterus by a healthcare provider. Hormonal IUDs release progestin, while non-hormonal IUDs use copper, both preventing fertilization and implantation.</li>
	<li>Tubal ligation involves closing or blocking the fallopian tubes, while bilateral salpingectomy removes the fallopian tubes entirely, providing permanent contraception.</li>
	<li>The effectiveness of each method varies, ranging from highly effective (e.g., hormonal IUDs, sterilization) to moderately effective (e.g., birth control pills) and less effective (e.g., barrier methods if not used consistently and correctly).</li>
	<li>Different methods may have side effects such as changes in the menstrual cycle, hormonal imbalances, or potential risks. Individual health, lifestyle, and preferences should be taken into account when selecting a contraceptive method.</li>
	<li>It is essential to consult with a healthcare provider to discuss options, understand the benefits, risks, and effectiveness of each method, and choose the most suitable contraceptive method based on individual circumstances. 
	&nbsp;</li>
</ul>

[1] Family Planning/Contraception Methods. World Health Organization.

[2] Siddiqui M, Fatima K, Ali SN, et al. Prevalence and Predictors of Contraception Usage in Karachi, Pakistan. Cureus. 2020;12(10):e11265. Published 2020 Oct 30. doi:10.7759/cureus.11265

[3] Annual Contraceptive Performance Report - 2020-21. Pakistan Bureau of Statistics.

[4] Abdullah, M., Bilal, F., Khan, R. et al. Raising the contraceptive prevalence rate to 50% by 2025 in Pakistan: an analysis of number of users and service delivery channels. Health Res Policy Sys 21, 4 (2023).