Published February 12 2018
In Part 1 of this article I went into detail about oral contraceptives, including both the risks and benefits. In Part 2, I will talk about some of the other methods of contraception, including IUDs, skin patches, vaginal rings, and some natural options.
What You Need To Know About IUDs
IUD is short for intrauterine device. The device is a “T” shape, and it is inserted through a woman’s cervix, and the upper part of the “T” rests on top of the cervix. IUD’s can contain hormones delivered directly to the reproductive organs (like Mirena), or the IUD can be non-hormonal – made of copper.
These devices must be inserted and removed by a medical professional. Depending on what type of IUD you have they typically last from 5-10 years, giving women freedom from taking a pill every day to avoid pregnancy.
What’s interesting about IUDs is that they don’t necessarily stop ovulation from occurring. In the hormonal IUD, very small amounts of synthetic hormones are released that create a thick wall of mucus around the cervix, making it difficult for sperm to get through. Copper IUDs cause inflammation in the uterus, which makes it inhospitable for fertilized eggs to find a nice warm home to live for nine months (1). The copper IUD is also toxic to sperm, and they die when they encounter it.
Benefits of IUDs
In addition to preventing pregnancy, some of the other benefits associated with the use of hormonal IUD’s include the following (2):
- Decrease in menstrual bleeding
- Reduced uterine fibroids
- Decreased incidence of endometriosis
Some of these benefits relate to reducing symptoms, and as I discussed with oral contraceptives in Part 1, we don’t want to mask symptoms. We ultimately want to find the root cause, so decreasing the risk of endometrial cancer seems like the biggest benefit to me if a woman has a strong history of this type of cancer in her immediate family. That being said, I realize that many women who get IUDs do so not for symptom management, but as a type of birth control.
Risks of IUDs
Now that you know some of the benefits of the IUD, let’s look at the risks involved. Perhaps the greatest risk of all with the IUD is the increased risk of pelvic inflammatory disease (5) (6). Pelvic inflammatory disease (PID) is an infection-caused inflammatory condition present from the cervix to the peritoneal cavity (7). It is commonly associated with fallopian tube inflammation, which can lead to infertility, ectopic pregnancy, and chronic pelvic pain (7).
Another risk of having an IUD inserted is the small chance for uterine perforation (8) (9). The scariest side effects are those requiring surgery, and uterine perforation fits this category. Granted, the risk of uterine perforation is low, as approximately 0.12-0.68 out of 1000 insertions go onto be perforations (10). However, even though it is rare, perforation of the uterus by an IUD is a serious complication, and this can occur during insertion or later. The chances of it happening are also increased six-fold for women who are breastfeeding (11).
While the hormonal IUD can reduce menstruation length and symptoms, the copper IUD can do the opposite, increasing menstrual blood loss by 50-100% compared to preinsertion levels (12).
Can a Copper IUD Cause a Copper Toxicity?
There is also a concern about copper IUDs potentially causing a copper toxicity in some women. Copper is a trace mineral the body uses along with iron to create red blood cells. Too much copper can cause problems though, and so I do suggest for women with copper IUDs to check their copper levels at least annually, as copper levels can increase after insertion of a copper IUD (13). This doesn’t mean that every woman who has a copper IUD will develop a copper toxicity, although it still can be a concern.
I’m not especially fond of the idea of implanting either a copper or hormonal IUD in a woman’s body, but I would prefer for my patients to have an IUD when compared to oral hormonal birth control options, as there are more risks involved with the pill. In addition, for those with thyroid and autoimmune thyroid conditions, remission can be harder to achieve for the reasons I mentioned in Part 1. As a result, the IUD is not my recommended birth control option for my patients.
Let’s take a look at some of the other contraceptive methods:
Skin patch. The patch is a small, thin, adhesive square that is applied to the skin, and it releases the hormones estrogen and progestin (14). The patch is changed once a week during the first three weeks of the menstrual cycle, and no patch is worn during the fourth week. Of six trials involving the skin patch, five compared the patch to birth control pills, and the pregnancy rate was similar, although the patch caused more symptoms including breast discomfort, painful periods, nausea, and vomiting (14).
Vaginal ring. The contraceptive vaginal ring is a flexible device that is inserted into the vagina, and like the patch, it also releases estrogen and progestin into the bloodstream through the wall of the vagina (15). They are inserted deep into the vagina and taken out again after 21 days by the woman (16). Regarding pregnancy rates, it is also comparable to oral contraceptives, although not surprisingly, users of the vaginal ring tend to have more vaginal irritation and discharge (15). However, they had less nausea, acne, irritability, depression, and fewer bleeding problems (15).
Barrier methods. Unlike the other contraceptive methods discussed, condoms not only prevent unwanted pregnancies, but they also prevent the spread of STDs. There are both male and female condoms, and both can help prevent pregnancy, although a lot of women find female condoms difficult to use.
Diaphragms are another option, as they are inserted into the vagina and completely cover the cervix, and a gel containing a spermicide is applied to the diaphragm beforehand. Then the diaphragm is inserted into the vagina prior to having sex, and it must be left in place for at least six hours after intercourse (17). A gynecologist will determine the correct size of the diaphragm (17), and if used properly they can be very effective.
Tubal ligation. This is also known as having your tubes tied, and is a permanent type of birth control. This procedure involves the fallopian tubes being cut, tied, or blocked in order to prevent pregnancy. Tubal ligation will prevent an egg from traveling from the ovaries through the fallopian tubes. While surgery can be done to try to reverse the procedure, this isn’t always effective. As a result, tubal ligation shouldn’t be taken lightly.
Vasectomy. While most of the methods of birth control mentioned have related to women, this information probably would be incomplete without bringing up the vasectomy. This procedure is done by cutting and sealing the tubes that carry the sperm (the vas deferens). This is also considered to be a permanent form of birth control, although like tubal ligation, a vasectomy reversal is a possibility.
My Preferred Method of Birth Control
I prefer a type of birth control that does not have all the risks of synthetic, hormone-based pills, and does not come with the potential complications of an implanted medical device. And I’m also not a big fan of male and female surgical sterilization. I think it’s safe to say that most women want a birth control method with the absolute least amount of side effects, but also want a method that works well at avoiding unwanted pregnancies.
For the remainder of this article, I’m going to discuss my birth control method of choice for my family and for my patients – the Fertility Awareness Method.
This method is not new, and you may remember learning about the rhythm method back in health class many years ago. The truth is, women have been charting their cycles for a very long time, and they have been using that information to avoid or achieve pregnancy. The Fertility Awareness Method has a 95% effectiveness rate with perfect use (18).
Technology has come a long way over the years, and the old-fashioned rhythm method has been jazzed up with fancy thermometers and corresponding apps that take all the work out of charting and calculating – you never have to think about when the first day of your last period was, how long a sperm can live, or how fast it can swim.
Women are only fertile on average of six days per cycle (19). Six days! Why would you pop a pill every day, or have a device implanted for contraceptive purposes, if you can only get pregnant six days out of a month? Some women are under the misconception that they can get pregnant any time during the month, and this simply isn’t true.
Signs of Fertility
The body gives very clear signs of fertility when it’s ovulating. For starters, the cervical mucus changes. When fertile, the cervical mucus becomes slippery and has the appearance of a raw egg white. This is the body’s way of helping the sperm meet the egg, and this is also a good indication of ovulation.
Your body also has measurable changes in basal temperature during ovulation. When a woman ovulates, her basal body temperature rises .5 to 1.0 degree, and her temperature stays elevated until her next period. The apps on the market now are using basal body temperature, along with sophisticated algorithms to calculate fertility to take all the guesswork out of it, while increasing the rate of effectiveness as compared to the old-school rhythm method.
I understand every woman is different, and each woman takes into account a number of factors when choosing a birth control method. What I don’t like, is that more women are not being informed of these advances in fertility technology by their doctors. Most doctors only recommend hormonal birth control, IUD’s, or tubal ligation. The majority don’t mention the fertility awareness method as even being an option, and if women are not presented with complete information, how can they be expected to make the best decision for themselves and their families?
Fertility Apps to Consider
There are a couple of apps that come highly recommended, and have excellent Pearl effectiveness ratings. The Pearl Index is used to report the effectiveness of a certain birth control method, as it’s defined as the number of pregnancies occurring per 100 woman during 1 year of use of a contraceptive agent. For example, a failure rate of 10% means that 10 out of 100 women become pregnant during the first year of using a specific contraceptive agent.
The first company I recommend, Daysy, has a Pearl Index rating of 0.7. To give you an idea of just how effective that is, birth control pills have a Pearl Index between 0.1 and 0.9, and so the Daysy method seems like an excellent choice for birth control. This method also comes highly recommended by my assistant Kate, who has been using it for years with no unintended pregnancies.
Another option is an app called Natural Cycles. This is very similar to the Daysy, as it uses basal body temperature to calculate fertility. This app has been certified in Europe as a medical device intended to be used for contraception, and it’s also an excellent choice. In fact, I came across an observational study that investigated the contraceptive efficacy of the Natural Cycles application (20). They concluded that the efficacy of a contraceptive mobile application is higher than usually reported for traditional fertility awareness-based methods (20).
Both apps above require investments, and so for those on a tight budget, the next set of recommendations are free. These apps don’t do quite as much as Daysy or Natural Cycles, so you may need to do some calculating on your own.
I’m sure there will be a few women reading this article who got pregnant using one of the apps listed. Even with the apps that have a lower Pearl Index, there still is a risk of the application falsely attributing a safe day within the fertile window, although this is more common with the free apps. Either way, these apps aren’t perfect, but neither is hormonal birth control. Everything of course comes down to risks vs. benefits, and without question these apps can greatly improve the effectiveness of fertility awareness-based methods, providing that couples protect themselves on fertile days.
How To Figure Out Your Fertile Window
If you are using one of the free apps, and need to figure out your own fertile window, I will quickly explain how to do this. The first thing you need to do is keep track of your cycle for at least a few months.
Every woman’s cycle varies in length, but the average cycle length is 28 days. The first day of a woman’s period is day 1 of her cycle, and it ends on the last day before her next period.
If you want to calculate your fertile window, you take your shortest cycle and subtract 18 from the length. This is the first day of your fertile window. You then subtract 11 from the longest cycle, and this is the last fertile day of a woman’s cycle. Once you know when you are fertile, you can avoid intercourse, or you can use a barrier method (such as a condom) as a back-up method. Once you are out of the fertile window, a woman can have as much unprotected sex as she wants, and not get pregnant.
As easy as this sounds, it does require thought and planning, and for some women, the margin for error is unacceptable, for obvious reasons. The free apps have a Pearl index rating of 7.0%, which admittedly, is high for someone who absolutely does not want to get pregnant. In which case, I would recommend one of the more sophisticated apps like Daysy or Natural Cycles.
Hopefully, this article has shed some light onto the topic of birth control, especially for those with thyroid and autoimmune thyroid conditions who are trying to make the best decision for their health. There is a better way than taking synthetic hormones, or implanting medical devices to avoid pregnancy. Of course I understand those women who use these methods for medical reasons, but for those who are simply wanting to avoid pregnancy, why take all the risks if they aren’t necessary?