tag:theconversation.com,2011:/global/topics/contraceptives-20459/articlesContraceptives – The Conversation2023-07-13T22:34:32Ztag:theconversation.com,2011:article/2042302023-07-13T22:34:32Z2023-07-13T22:34:32ZFDA approves first daily over-the-counter birth control pill, Opill – a pharmacist and public health expert explain this new era in contraception<figure><img src="https://images.theconversation.com/files/537358/original/file-20230713-15-64cjm9.jpg?ixlib=rb-1.1.0&rect=49%2C35%2C4643%2C3067&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The progestin-only pill Opill could be available in early 2024.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/empty-shopping-basket-on-pharmacy-drugstore-counter-royalty-free-image/1013458454">Kwangmoozaa/iStock via Getty Images</a></span></figcaption></figure><p>On July 13, 2023, the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-nonprescription-daily-oral-contraceptive">U.S. Food and Drug Administration approved</a> a drugmaker’s application for the first daily over-the-counter birth control pill for people seeking to prevent pregnancy.</p>
<p>The pill, called Opill – the brand name for the tablet formulation of norgestrel – is an oral contraceptive containing only progestin hormone, which helps prevent pregnancy by thickening cervical mucus, preventing ovulation or both. Opill was initially approved <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/opill-0075mg-oral-norgestrel-tablet-information">by the FDA for prescription use in 1973</a>. Its approval for nonprescription use may spark other manufacturers of prescription-only birth control to follow. This highlights the importance of pharmacies as destinations for health care and pharmacists as facilitators of contraceptive care.</p>
<p>Opill is expected to be available through pharmacies, supermarkets, convenience stores and online retailers in early 2024. The FDA’s approval of an over-the-counter birth control pill can further expand options for people seeking hormonal contraception to all 50 states and U.S. territories. This expanded access could be a significant development in the post-Roe era as <a href="https://theconversation.com/one-year-after-the-fall-of-roe-v-wade-abortion-care-has-become-a-patchwork-of-confusing-state-laws-that-deepen-existing-inequalities-207390">individual states further restrict</a> women’s access to abortion. </p>
<p>Prior to the FDA’s approval of this pill, many U.S. states have allowed pharmacists to prescribe hormonal contraception. The process begins <a href="https://birthcontrolpharmacist.com/">with a pharmacist consultation</a> to screen patients for eligibility, collect a medical history and measure blood pressure. If the patient qualifies, the pharmacist can provide a prescription to the patient; if not, the pharmacist refers the patient to a physician. </p>
<p>We are a <a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">pharmacist</a> and a <a href="https://scholar.google.com/citations?hl=en&user=OIT2K2oAAAAJ">public health expert</a>. We see the move toward over-the-counter birth control as an important step toward accessible and equitable reproductive health care for all Americans. Even though this product will be over-the-counter, pharmacists will play an indispensable role in that effort.</p>
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<figcaption><span class="caption">The FDA’s approval of the first-ever over-the-counter daily birth control pill means that people could soon get them from the same aisles as aspirin, eye drops or condoms.</span></figcaption>
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<h2>Making birth control more accessible</h2>
<p><a href="https://doi.org/10.1016/j.japh.2022.07.003">With more than 60,000 pharmacies nationwide</a>, pharmacists are the most accessible members of the health care workforce. Nearly 90% of Americans live within <a href="https://doi.org/10.1016/j.japh.2022.07.003">5 miles of a pharmacy</a>. Throughout the COVID-19 pandemic, pharmacies have provided testing, vaccination and treatment for millions of people in the U.S., <a href="https://theconversation.com/how-the-test-to-treat-initiative-aims-to-get-ahead-of-the-next-wave-of-covid-19-179607">proving their worth</a> in supporting and sustaining initiatives that are important to public health. </p>
<p>Traditionally, hormonal contraception – also known as birth control, or when taken orally, “the pill” – has only been accessible after a comprehensive medical evaluation by a physician, physician assistant or nurse practitioner. </p>
<p>But in 2016, California and Oregon changed their legislation to allow pharmacists to prescribe birth control. That quickly expanded to 20 states, plus Washington, D.C., that now <a href="https://naspa.us/resource/contraceptives/">allow pharmacists to prescribe</a> some form of birth control, whether it be the pill, patch, ring or shot.</p>
<p>However, the move toward over-the-counter birth control is important because it will lessen some of the known barriers to birth control, especially if the products are offered at an affordable price point. These barriers include the inability to pay for medical office visits required to obtain a prescription, lack of insurance to cover the cost of prescription birth control or lack of access to pharmacist-prescribed contraception.</p>
<p>Over-the-counter birth control can also reduce access barriers by preventing the need for a scheduled appointment with a primary care physician during work hours, the need for a pharmacist to be present to dispense prescription birth control or the need to travel long distances to access these professionals. </p>
<p>But it is important to note that over-the-counter access to hormonal birth control does not replace the importance of regular office visits or discussion about reproductive health with physicians.</p>
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<figcaption><span class="caption">The use of contraception was illegal in the U.S. from the late 1800s until the 1960s.</span></figcaption>
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<h2>Addressing remaining barriers</h2>
<p>Even in states where pharmacists are currently allowed to prescribe birth control, over-the-counter hormonal birth control can make a difference.</p>
<p>For example, if state policies do not create payment pathways to reimburse pharmacists for their time to counsel and prescribe, pharmacists may choose not to participate in prescribing birth control. Additionally, pharmacist availability and time may be limited and more restricted than the hours a pharmacy is advertised as open to the public to sell over-the-counter birth control products.</p>
<p>Finally, there are notable cases of pharmacists who have denied patients access to emergency contraception, also known as the “morning-after pill,” and <a href="https://www.npr.org/2018/06/25/623307762/walgreens-pharmacist-denies-drug-for-woman-with-unviable-pregnancy">prescriptions for medication abortion</a> on the grounds of moral, ethical and religious beliefs. </p>
<p>For instance, in 2019, a pharmacist in Minnesota <a href="https://www.nbcnews.com/news/us-news/minnesota-pharmacist-trial-refusing-dispense-morning-pill-beliefs-rcna41030">denied a patient emergency contraception</a>, citing personal beliefs. As a result, the patient drove 50 miles <a href="https://www.washingtonpost.com/nation/2022/08/03/minnesota-pharmacist-contraception-lawsuit/">to gain access to the medication</a>. Ultimately, a jury found that the pharmacist did not discriminate against the woman by denying to fill her prescription.</p>
<p>This precedent suggests that pharmacists who object to the use of reproductive medications may further choose not to participate in prescribing hormonal contraception even when permitted to do so by state law. Individuals may also choose not to stock over-the-counter birth control when it becomes available.</p>
<h2>Pharmacist ‘conscience clauses’</h2>
<p>Notably, many states give pharmacists autonomy when dispensing medications. Currently, 13 states have laws or regulations known as “conscience clauses” that <a href="https://www.nbcnews.com/news/us-news/can-pharmacist-legally-deny-patient-prescription-it-depends-n894871">permit pharmacists to refuse to dispense a medication</a> when it conflicts with their religious or moral beliefs. </p>
<p>The American Pharmacists Association also recognizes an individual pharmacist’s right to conscientiously refuse to dispense a medication; however, the organization supports a system to <a href="https://aphanet.pharmacist.com/policy-manual?key=Pharmacist+Conscience+Clause&op=Search">ensure patient access to medications</a> without compromising the pharmacist’s right of refusal. In other words, pharmacists are encouraged to “step aside” but should not “step in the way” of dispensing or selling medications that conflict with their personal beliefs. </p>
<p>Some states with conscience clauses legally require pharmacists to refer patients elsewhere when they decline to dispense a medication for ethical and/or moral beliefs. In addition, company policies may require pharmacists with objections to arrange for another pharmacist – who does not have objections – to provide the medication and care requested by the patient. However, some states do not require a system to ensure this patient access as the American Pharmacists Association suggests.</p>
<p>Pharmacist conscience clauses are unlikely to interfere with over-the-counter birth control availability at large pharmacy chains, supermarkets and mass merchandisers due to top-down decision-making structures of these organizations. However, national pharmacy chains have recently faced <a href="https://www.nytimes.com/2023/03/07/business/walgreens-abortion-pill.html">complicated legal and political situations</a> when it comes to offering prescription abortion pills in the post-Roe era.</p>
<p>Ongoing <a href="https://www.guttmacher.org/state-policy">legislation seeking to reduce abortion access</a> in the post-Roe era across the U.S. only increases the importance of patient access to contraception. Geographical spatial analyses have found that people of low socioeconomic classes and of color <a href="https://read.dukeupress.edu/jhppl/article/46/2/277/166722/Affordable-but-Inaccessible-Contraception-Deserts">disproportionately reside in contraception deserts</a>, which are areas with low access to family planning resources. These contraception deserts could be reduced or eliminated altogether now that retailers may sell over-the-counter hormonal birth control at an affordable price. </p>
<h2>Pharmacists’ role in providing contraceptive</h2>
<p>Although patients may seek and purchase over-the-counter hormonal birth control at locations other than community pharmacies, when patients come to a pharmacy, pharmacists can help them understand how to use the product correctly, safely and effectively prior to purchase. Pharmacists are trained as medication experts and acquire unique knowledge and skills of self-care products and nonprescription medications. When a pharmacist feels it is necessary, they can refer patients who do not qualify for over-the-counter birth control use back to their primary care providers for further evaluation and care.</p>
<p>In our view, pharmacists can positively contribute to the safe, effective and accessible use of contraception across the country.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/with-over-the-counter-birth-control-pills-likely-to-be-approved-pharmacists-and-pharmacies-could-play-an-ever-increasing-role-in-reproductive-health-care-189216">article originally published</a> on Oct. 28, 2022.</em></p><img src="https://counter.theconversation.com/content/204230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is part owner of the consulting company, Embarx, LLC.</span></em></p><p class="fine-print"><em><span>Marian Jarlenski does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With the approval of the first over-the-counter oral contraceptive, pharmacists stand to play an ever-increasing role in helping expand access to reproductive health care in the post-Roe era.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghMarian Jarlenski, Associate Professor of Health Policy and Management, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1940672022-11-14T13:07:18Z2022-11-14T13:07:18ZAs the 8 billionth person is born, here’s how Africa will shape the future of the planet’s population<figure><img src="https://images.theconversation.com/files/494071/original/file-20221108-26-rjbg6o.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p><em>In mid-November 2022 the eight billionth person will be born, <a href="https://www.un.org/en/dayof8billion#:%7E:text=On%2015%20November%202022%2C%20the,nutrition%2C%20personal%20hygiene%20and%20medicine">according to the United Nations</a>. In its analysis of this milestone, the UN makes two key observations. The first is that the global population has been expanding at its slowest rate since 1950. The growth rate dropped below 1% in 2020, a trend that is likely to continue. The second is that the growth in population has been due to the gradual increase in human lifespan owing to improvements in public health, nutrition, personal hygiene and medicine. It’s also the result of high and persistent levels of fertility in some countries. According to the UN, just eight countries are <a href="https://www.un.org/en/desa/world-population-reach-8-billion-15-november-2022">expected</a> to be behind 50% of the population growth over the next 30 years. Five are in Africa: the Democratic Republic of Congo, Egypt, Ethiopia, Nigeria and Tanzania. Demographers Akanni Akinyemi, Jacques Emina and Esther Dungumaro unpack these dynamics.</em></p>
<h2>What’s the significance of the eight billionth birth?</h2>
<p>It raises concerns – <a href="https://worldpopulationhistory.org/carrying-capacity/">scientists estimate</a> that Earth’s maximum carrying capacity is between nine billion and 10 billion people. </p>
<p>Appreciating these numbers requires an understanding of the distribution and demographic structure of the population. Where are these people across regions, countries, and rural and urban geographies?</p>
<p>There is a potential upside to growing populations. It’s known as a <a href="https://www.unfpa.org/demographic-dividend#0">demographic dividend</a>. Population growth can be a blessing, spurring economic growth from shifts in a population’s age structure. This is a prospect if working-age people have good health, quality education, decent employment and a lower proportion of young dependants. </p>
<p>But realising this dividend depends on a host of things. They include the structure of the population by age, level of education and skills, and living conditions, as well as the distribution of available resources. </p>
<p>The consequences of population growth are socioeconomic, political and environmental. Some of them can be negative. How these unfold is determined by the characteristics of the population and its distribution. </p>
<h2>Why are birth rates so high in five African countries?</h2>
<p>The major factors driving population growth in these countries include low contraceptive use, high adolescent fertility rates and a prevalence of polygamous marriages. There’s also the low education status of women, low to poor investment in children’s education, and factors related to religion and ideas. </p>
<p>The use of modern contraceptives is <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-022-01332-x#:%7E:text=The%20use%20of%20modern%20contraceptives,%2DSaharan%20Africa%20(SSA);%20%20un_2019_contraceptiveusebymethod_databooklet.pdf">generally low</a> across sub-Saharan Africa. The overall prevalence is 22%. In the Democratic Republic of Congo, however, the uptake of short-acting contraceptives is at 8.1%. In Nigeria, it is at 10.5%. The uptake in Ethiopia is 25%, in Tanzania it’s 27.1% and in Egypt 43%.</p>
<p>For long-acting family planning methods, apart from Egypt with over 20% uptake, the other four countries driving population growth in the region recorded very poor uptake. This low uptake will logically lead to a population explosion. </p>
<p>Some of the factors <a href="https://contraceptionmedicine.biomedcentral.com/articles/10.1186/s40834-021-00165-6">associated</a> with high contraceptive use in Africa are women’s education, exposure to news and mass media, good economic status and urban residency.</p>
<p>The adolescent fertility rate in sub-Saharan Africa – while showing a downward trend – is still relatively high. The adolescent fertility rate captures the number of births per 1,000 girls aged 15 to 19. In sub-Saharan Africa, it stands at an average of <a href="https://data.worldbank.org/indicator/SP.ADO.TFRT?locations=ZG">98 births per 1,000 girls</a>.</p>
<p>There is a <a href="https://data.worldbank.org/indicator/SP.ADO.TFRT?locations=ZG">wide variation</a> in this rate across the five countries: from 52 in Egypt and 62 in Ethiopia to 102 in Nigeria, 114 in Tanzania and 119 in the DRC. </p>
<p><a href="https://www.statista.com/statistics/1228319/adolescent-fertility-rate-worldwide/">Outside the continent</a>, the adolescent fertility rate is 21 in Asia and the Pacific, and 26 in Eastern Europe and Central Asia. In the US, it’s at 15, five in France and 42 globally. </p>
<p>The adolescent fertility rate has huge implications for population growth because of the number of years between the start of childbearing and the end of a woman’s reproductive age. A high fertility rate in this age group also has a negative influence on the health, economic and educational potential of women and their children. </p>
<p>Another factor driving population growth in these five African countries is polygamous marriage. Women in polygamous unions living in rural areas with low socio-economic status are likely to have higher fertility rates than women in other areas. </p>
<p>Polygamy is <a href="https://www.africanews.com/2022/04/05/polygamy-in-drc-illegal-but-not-uncommon//">illegal in the DRC</a>. Nevertheless, it’s common. About 36% of married women in <a href="https://www.prb.org/resources/polygamy-in-west-africa-impacts-on-fertility-fertility-intentions-and-family-planning/">Nigeria</a>, one-quarter of married women in <a href="https://www.reuters.com/article/tanzania-marriage-idINKCN0SL0CP20151027">rural Tanzania</a> and 11% of those in <a href="https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-022-00753-4#:%7E:text=Regarding%20Ethiopia%2C%20polygamy%20is%20practiced,co%2Dwives%20%5B10%5D">Ethiopia</a> are in polygamous marriages.</p>
<p>Finally, a woman’s education status has a significant impact on fertility. For instance, in Tanzania, women with no formal education have as many as <a href="https://www.reuters.com/article/tanzania-marriage-idINKCN0SL0CP20151027">3.3 more children</a> than women with secondary or tertiary education. </p>
<h2>Are rising populations a cause for major concern in these countries?</h2>
<p>Yes. </p>
<p>One of the biggest concerns is the scale of these countries’ development.</p>
<p>The World Bank classifies the DRC among the <a href="https://www.worldbank.org/en/country/drc/overview">five poorest nations in the world</a>, with nearly 64% of the population living on less than US$2.15 a day. One in six of sub-Saharan Africa’s poorest people is found in the DRC. </p>
<p>In Nigeria, about <a href="https://www.worldbank.org/en/country/nigeria/overview">40% of the population</a> lives below the poverty line. The west African nation also faces issues of insecurity, poor infrastructure and high unemployment.</p>
<p>Steady population growth in these five countries will exert further stress on already inadequate infrastructure and services.</p>
<p>Also, the age structure of the populations of these five countries reflects high levels of dependency. The population of young people who aren’t in the labour force and that of older people is far higher than of those in their prime ages (18 to 64) who are gainfully employed. </p>
<p>There is also a potential shortage of working-age people with high skills compared with the population of those who depend on them for survival in these five countries. </p>
<p>This is because these countries have a <a href="https://www.statista.com/statistics/1121264/median-age-in-africa-by-county/">very youthful population</a>. The median age ranges from 17 in the DRC to 17.7 in Tanzania and 18.8 in Nigeria. There is also the prospect of many young people living in unfavourable socioeconomic realities and poverty.</p>
<h2>In most countries, population growth is the slowest since 1950. Why?</h2>
<p>Most countries, particularly in America, Asia, Europe, Oceania and North Africa, have completed the fertility transition. In other words, they are experiencing below-replacement fertility levels – fewer than two children are being born per woman. </p>
<p>The main drivers of low fertility include the increased use of modern contraceptives, increased age at first marriage and higher numbers of educated women.</p>
<h2>What should the next steps be for African countries with high fertility rates?</h2>
<p>Government policies and programmes need to take into account population growth and align interventions with sustainable use and access to resources. </p>
<p>Governments at regional, national and sub-national levels also need to invest in infrastructure and education. They need to create employment if they are to benefit from a growing population. There is also need to continue investing in family planning. </p>
<p>The age structure of the population is also of concern. The expected growth in population numbers is <a href="https://www.unfpa.org/8billion/8trends">likely to increase</a> the concentration of young people and those of prime ages. With limited socio-economic opportunities for young people, countries are more likely to be subject to the forces of international migration. </p>
<p>The proportion of older people is also likely to increase in the five countries in focus. This increases the need for investment in social security, infrastructure and innovative support for older people. Unfortunately, issues around older people have not gained prominence on the continent.</p><img src="https://counter.theconversation.com/content/194067/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacques Emina
Population and Health Research Institute
and with
School of Population and Development Studies, University of Kinshasa</span></em></p><p class="fine-print"><em><span>Akanni Ibukun Akinyemi and Esther William Dungumaro do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Eight countries are projected to be behind 50% of the growth in population over the next three decades. Five are in Africa.Akanni Ibukun Akinyemi, Professor of Demography and Social Statistics., Obafemi Awolowo UniversityEsther William Dungumaro, Associate Professor of Demography, University of Dar es SalaamJacques Emina, Professor of population and development studies, University of Kinshasa Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892162022-10-28T12:32:36Z2022-10-28T12:32:36ZWith over-the-counter birth control pills likely to be approved, pharmacists and pharmacies could play an ever-increasing role in reproductive health care<figure><img src="https://images.theconversation.com/files/487887/original/file-20221003-22-rx39dq.jpg?ixlib=rb-1.1.0&rect=395%2C0%2C5595%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The over-the-counter birth control pill will not require medical examinations or prescriptions prior to purchase.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cheerful-woman-in-modern-pharmacy-royalty-free-image/1360043428?phrase=pharmacy&adppopup=true">Sergey Mironov/Moment via Getty Images</a></span></figcaption></figure><p>The U.S. Food and Drug Administration is <a href="https://www.reuters.com/legal/us-fda-review-perrigos-birth-control-pill-otc-use-november-2022-09-12/">set to review</a> a drugmaker’s application for the <a href="https://www.statnews.com/2022/07/11/drugmaker-seeks-fda-approval-of-over-the-counter-birth-control-pill/">first over-the-counter birth control pill</a> in November 2022, with a decision expected in the first half of 2023. </p>
<p>An approved over-the-counter hormonal birth control product would not require a prescription and <a href="https://www.selfcarefederation.org/what-is-self-care">would be considered self-care</a>, defined as “the practice of individuals looking after their own health using the knowledge and information available to them.” </p>
<p>Currently, in many U.S. states, pharmacists can already prescribe hormonal contraception that requires a prescription. The process begins <a href="https://birthcontrolpharmacist.com/">with a pharmacist consultation</a> to screen patients for eligibility, collect a medical history and measure blood pressure. If the patient qualifies, the pharmacist can provide a prescription to the patient; if not, the pharmacist refers the patient to a physician. </p>
<p>The FDA’s approval of an over-the-counter birth control pill will further expand options for people seeking hormonal contraception to all 50 states. The first such over-the-counter pill – <a href="https://www.reuters.com/legal/us-fda-review-perrigos-birth-control-pill-otc-use-november-2022-09-12/">a non-estrogen, progestin-only contraceptive</a> – could become available by mid-2023. </p>
<p>We are a <a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">pharmacist</a> and a <a href="https://scholar.google.com/citations?hl=en&user=OIT2K2oAAAAJ">public health expert</a>. We see the move toward over-the-counter birth control as an important step toward accessible and equitable reproductive health care for all Americans, and pharmacists will play an indispensable role in that effort.</p>
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<figcaption><span class="caption">The FDA will consider the application from HRA Pharma in November 2022.</span></figcaption>
</figure>
<h2>Making birth control more accessible</h2>
<p><a href="https://doi.org/10.1016/j.japh.2022.07.003">With more than 60,000 pharmacies nationwide</a>, pharmacists are the most accessible members of the health care workforce. Nearly 90% of Americans live within <a href="https://doi.org/10.1016/j.japh.2022.07.003">5 miles of a pharmacy</a>. Throughout the COVID-19 pandemic, pharmacies provided testing, vaccination and treatment for millions of people in the U.S., proving their worth in supporting and sustaining initiatives that are important to public health.</p>
<p>Traditionally, hormonal contraception – also known as birth control, or when taken orally, “the pill” – has only been accessible after a comprehensive medical evaluation by a physician, physician assistant or nurse practitioner. </p>
<p>But in 2016, California and Oregon became the first states to allow pharmacists to prescribe birth control. That quickly expanded to 20 states plus Washington, D.C. that now <a href="https://naspa.us/resource/contraceptives/">allow pharmacists to prescribe</a> some form of birth control, whether it be the pill, patch, ring or shot.</p>
<p>However, the move toward nonprescription-based, over-the-counter birth control is important because it will greatly lessen some of the known barriers to birth control. These barriers include the inability to pay for medical office visits required to obtain a prescription, lack of insurance to cover the cost of prescription birth control or lack of accessibility to pharmacist-prescribed contraception.</p>
<p>Over-the-counter birth control can also reduce access barriers by preventing the need for a scheduled appointment with a primary care physician during work hours or the need to travel long distances to get such care.</p>
<p>But it is important to note that over-the-counter access to hormonal birth control does not replace the importance of regular office visits or discussion about reproductive health with physicians.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/WZ7fp8j1uUU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The use of contraception was illegal in the U.S. from the late 1800s until the 1960s.</span></figcaption>
</figure>
<h2>Addressing remaining barriers</h2>
<p>Even in states where pharmacists are currently allowed to prescribe birth control, patients may still face barriers. </p>
<p>For example, if state policies do not create payment pathways to reimburse pharmacists for their time to counsel and prescribe, pharmacists may choose not to participate. Additionally, pharmacist availability and time may be limited and more restricted than the hours a pharmacy is advertised as open.</p>
<p>Finally, there are notable cases of pharmacists who have denied patients access to emergency contraception, also known as the “morning-after pill,” and <a href="https://www.npr.org/2018/06/25/623307762/walgreens-pharmacist-denies-drug-for-woman-with-unviable-pregnancy">prescriptions for medication abortion</a> on the grounds of moral, ethical and religious beliefs. </p>
<p>For instance, in 2019, a pharmacist in Minnesota <a href="https://www.nbcnews.com/news/us-news/minnesota-pharmacist-trial-refusing-dispense-morning-pill-beliefs-rcna41030">denied a patient emergency contraception</a>, citing personal beliefs. As a result, the patient drove 50 miles <a href="https://www.washingtonpost.com/nation/2022/08/03/minnesota-pharmacist-contraception-lawsuit/">to gain access to the medication</a>. Ultimately, a jury found that the pharmacist did not discriminate against the woman by denying to fill her prescription.</p>
<p>This precedent suggests that pharmacists who object to the use of reproductive medications may further choose not to participate in prescribing hormonal contraception even when permitted to do so by state law. They may also choose not to sell over-the-counter birth control when it becomes available.</p>
<h2>Pharmacist ‘conscience clauses’</h2>
<p>Notably, many states give pharmacists autonomy when dispensing medications. Currently, 13 states have laws or regulations known as “conscience clauses” that <a href="https://www.nbcnews.com/news/us-news/can-pharmacist-legally-deny-patient-prescription-it-depends-n894871">permit pharmacists to refuse to dispense a medication</a> when it conflicts with their religious or moral beliefs. </p>
<p>The American Pharmacists Association also recognizes an individual pharmacist’s right to conscientiously refuse to dispense a medication; however, the organization supports a system to <a href="https://aphanet.pharmacist.com/policy-manual?key=Pharmacist+Conscience+Clause&op=Search">ensure patient access to medications</a> without compromising the pharmacist’s right of refusal. In other words, pharmacists are encouraged to “step aside” but should not “step in the way” of dispensing or selling medications that conflict with their personal beliefs. </p>
<p>Some states with conscience clauses legally require pharmacists to refer patients elsewhere when they decline to dispense a medication for ethical and/or moral beliefs. In addition, company policies may require pharmacists with objections to arrange for another pharmacist – who does not have objections – to provide the medication and care requested by the patient. However, some states do not require a system to ensure this patient access as the American Pharmacists Association suggests.</p>
<h2>Contraception deserts</h2>
<p>Ongoing <a href="https://www.guttmacher.org/state-policy">legislation seeking to reduce abortion access</a> in the post-Roe era across the U.S. only increases the importance of patient access to contraception. Geographical spatial analyses have found that people of low socioeconomic classes and of color <a href="https://read.dukeupress.edu/jhppl/article/46/2/277/166722/Affordable-but-Inaccessible-Contraception-Deserts">disproportionately reside in contraception deserts</a>, which are areas with low access to family planning resources. These contraception deserts could be reduced or eliminated altogether in states that authorize pharmacists to prescribe contraception, or in areas with access to community pharmacies carrying hormonal birth control when available.</p>
<p>In our view, pharmacists can positively contribute to the safe, effective and accessible use of contraception across the country.</p><img src="https://counter.theconversation.com/content/189216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some states already allow pharmacists to provide birth control to patients with a prescription. But FDA approval of an over-the-counter birth control pill could greatly expand access.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghMarian Jarlenski, Associate Professor of Health Policy and Management, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1912962022-10-07T14:51:15Z2022-10-07T14:51:15ZBirth control pill linked to greater risk of blood clots in women with obesity – here’s what you need to know<figure><img src="https://images.theconversation.com/files/486508/original/file-20220926-21-vtaud.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5615%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The combined pill contains both oestrogen and progestin. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contraceptive-pill-174193232">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>Women who are obese and taking the combined oral contraceptive pill have 12 to 24 times greater risk of developing a leg-vein blood clot than those not taking the pill and who are not overweight, according to <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104">a recent review of research</a>. <a href="https://pubmed.ncbi.nlm.nih.gov/12624633/">Other studies</a> have found a lower but still increased risk.</p>
<p>This kind of blood clot, known as a <a href="https://www.nhs.uk/conditions/deep-vein-thrombosis-dvt/">deep venous thrombosis</a> (DVT), can cause pain, swelling and redness of the affected leg. Usually this pain happens in the calf or thigh. Fortunately, most DVTs aren’t fatal – but they are serious and need to be treated urgently. In a small number of cases, part of the clot can break off and travel to the lungs which can be life threatening. </p>
<p>This increased risk might seem scary, and could even put some women off using contraception altogether if they’re overweight. But it’s important to understand where that risk comes from. And that not all types of contraception carry this increased risk. </p>
<p>The first thing to understand about the evidence around blood clot risk and contraception is that it only applies to <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">contraceptive methods that contain oestrogen</a>. These are the <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">combined oral contraceptive pill</a>, the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-patch/">contraceptive patch</a> and the <a href="https://www.nhs.uk/conditions/contraception/vaginal-ring/">contraceptive vaginal ring</a>. </p>
<p>That means that for <a href="https://www.fsrh.org/standards-and-guidance/documents/ukmec-2016-summary-sheets/">all other methods available</a> the evidence doesn’t show an increased risk of developing a clot in healthy women who are not obese and don’t smoke. Smoking can also increase a person’s overall risk of blood clots, both in the leg and in the blood supply to the heart and brain. </p>
<p>The second thing to look at is the risk for all women of developing a clot, either while using contraception or not using it. </p>
<p>In general, the risk of developing a clot in the leg varies with age. But in young women worldwide, who are not using hormonal contraception, <a href="https://www.gov.uk/drug-safety-update/combined-hormonal-contraceptives-and-venous-thromboembolism-review-confirms-risk-is-small">around two in every 10,000</a> will develop a blood clot each year. This is very low.</p>
<figure class="align-center ">
<img alt="A clinician wearing blue surgical gloves holds a copper IUD between their fingers." src="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486509/original/file-20220926-23-5lozzg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Contraceptives that don’t contain oestrogen (such as the copper IUD) don’t carry an additional risk of blood clots.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2074498042">New Africa/ Shutterstock</a></span>
</figcaption>
</figure>
<p>But the risk of developing a blood clot while on the combined oral pill is between <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">two and six times higher</a> than for women not using the combined pill. This works out at about five to 12 women per 10,000 each year – depending on the type of combined pill. Older pills containing <a href="https://pubmed.ncbi.nlm.nih.gov/22027398/">levonorgestrel have the lowest risk</a>.</p>
<p>The risk of developing a blood clot on the combined pill is about the same as the risk of developing a clot <a href="https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/treatment-of-venous-thrombosis-in-pregnancy-and-after-birth-patient-information-leaflet/#:%7E:text=it%20in%20pregnancy%3F-,Pregnancy%20increases%20your%20risk%20of%20a%20DVT%2C%20with%20the%20highest,including%20the%20first%203%20months.">during or immediately after pregnancy</a>. The <a href="https://www.bmj.com/content/344/bmj.e2990">patch and vaginal ring</a>, which both contain oestrogen, increase the risks by about the same amount as the combined oral pill. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039863/">contraceptive injection</a> seems also to increase the risk by a small amount – but this risk is still less than oestrogen-containing birth control methods.</p>
<h2>Obesity and DVT</h2>
<p>Being overweight increases everyone’s chance of developing a DVT, and this seems to be <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">especially the case in women</a>. People who are considered obese (a <a href="https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/">BMI of over 30</a>) are at about a <a href="https://www.amjmed.com/article/S0002-9343(05)00207-X/fulltext">three to five times greater risk</a> of having a venous clot than those who have a healthy BMI. </p>
<p>There are two reasons that obesity increases risk of DVT. People who are obese have more abdominal fat, <a href="https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0031-1297369">which can slow the speed of blood flow</a> travelling from the legs and through the abdomen. This increases the chance of blood clotting. </p>
<p>Obesity also seems to cause <a href="https://www.webofscience.com/wos/woscc/full-record/WOS:000222655700008?SID=EUW1ED0AF0rjOMT19mVWZ8cXVTUpt">low-grade inflammation</a> in the body, which may make it easier for clots to form and may also make them <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">less likely to be dissolved naturally</a>.</p>
<p>Oestrogen has a similar effect to excess weight, also making the blood <a href="https://onlinelibrary.wiley.com/doi/10.1002/ehf2.14104#ehf214104-bib-0019">more likely to form clots</a> and less likely to dissolve small clots when they happen. This is why obesity can put women taking oestrogen-containing contraceptives at even greater risk of DVT. </p>
<p>To lower your risk of a blood clot in general, it’s best to maintain as healthy a weight as possible, to avoid smoking and keep an eye on your blood pressure. Since both obesity and oestrogen can increase the likelihood of a blood clot in the leg, it’s not surprising the combination of these two factors increases blood clot risk substantially. </p>
<p>If you are worried about your risk of a blood clot, that doesn’t mean you can’t use contraception. There are still many safe contraceptives you can choose from which do not contain oestrogen, and therefore do not increase risk of a clot. This includes condoms, the copper IUD (which contains no hormones) or the progesterone-only pill, intrauterine system or implant (which only contain progestogen).</p><img src="https://counter.theconversation.com/content/191296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has receives funding from Bayer and NaturalCycles.. </span></em></p>Although the study found greater risk of blood clots for obese women taking the pill, the risk of developing one was still very low.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1833672022-07-25T20:02:00Z2022-07-25T20:02:00ZWhat to expect when coming off the pill, and 5 things to do before you do<figure><img src="https://images.theconversation.com/files/471783/original/file-20220630-15-dvkid7.png?ixlib=rb-1.1.0&rect=0%2C5%2C3528%2C2359&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Unsplash/Drew Dizzy Graham</span></span></figcaption></figure><p>“The pill” (the combined oral contraceptive pill) has been giving Australian women control over their reproductive health since the 1960s and remains the <a href="https://www.ogmagazine.org.au/16/2-16/combined-oral-contraceptives/">most commonly used</a> method of contraception by Australian women. </p>
<p><a href="https://alswh.org.au/shorthand/reproductive-health-report/#group-section-The-Pill-QkSUaAOLBq">Its use peaks</a> with around 60% of Australian women in their late teens and early 20s using the pill, and drops to around 35% by the mid to late 20s. </p>
<p>Used perfectly, the pill <a href="https://shvic.org.au/for-you/contraception/daily-contraceptive-pills/contraceptive-pill">prevents pregnancy</a> 99.5% of the time, but in the real world where pills are occasionally forgotten it works 93% of the time. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-effective-is-the-pill-122189">How effective is the pill?</a>
</strong>
</em>
</p>
<hr>
<p>In Australia, half of the women who start on the pill won’t be taking it <a href="https://alswh.org.au/shorthand/reproductive-health-report/#group-section-The-Pill-QkSUaAOLBq">six months later</a>. Women come off the pill for lots of different reasons, including:</p>
<ul>
<li><p>trying to fall pregnant</p></li>
<li><p>trying a different contraceptive option</p></li>
<li><p><a href="https://www.bmj.com/content/bmj/3/5773/495.full.pdf">side effects</a> (including headaches, bloating, weight gain, not having a regular period, unpredictable nuisance or “breakthrough” bleeding, nausea, depression, reduced libido)</p></li>
<li><p>developing a medical condition where the pill is no longer safe (the most common of these is migraine or deep vein thrombosis, or smoking over the age of 35)</p></li>
<li><p>no longer needing contraception </p></li>
<li><p>wanting to know what their natural cycle and periods are like. </p></li>
</ul>
<p>If you’re preparing to come off the pill, it’s hard to know what to expect – particularly if you’ve been on it for a long time.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/theres-convincing-evidence-the-pill-can-cause-depression-and-some-types-are-worse-than-others-184248">There's convincing evidence the pill can cause depression, and some types are worse than others</a>
</strong>
</em>
</p>
<hr>
<h2>What may happen when you come off the pill</h2>
<p>Regardless of how long you’ve been taking the pill, the synthetic hormones are cleared from the body within days. Your body returns to releasing different amounts of oestrogen and progesterone throughout the cycle – although what’s “normal” for your body may have changed. </p>
<p>Teenagers can have irregular periods for the first few years before a more regular rhythm establishes. A lot might have changed since you first went on the pill – your body could have developed a medical condition, have a different lifestyle, changed size or shape, or had children. This can all impact how natural hormones in your body can impact you. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman looking off into sunset" src="https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471790/original/file-20220630-26-g8oyc7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Regardless of how long you’ve been taking the pill, the synthetic hormones are cleared from the body within days.</span>
<span class="attribution"><span class="source">Unsplash/artem kovalev</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Here are some of the changes you might expect when coming off the pill.</p>
<p><strong>Periods!</strong> </p>
<p>For many women, <a href="https://www.uptodate.com/contents/combined-estrogen-progestin-oral-contraceptives-patient-selection-counseling-and-use">periods come back within a month</a> of stopping the pill, with almost all women getting their period within three months. Your periods may start off irregular, but generally return to the natural menstrual cycle within three months. Women on the pill often have quite light periods, so coming off the pill you might experience heavier or longer periods. The natural cycle can also be impacted by exercise, diet, stress and underlying medical conditions. It’s a good idea to see a doctor if you haven’t got your period back within three months.</p>
<p><strong>Fertility</strong> </p>
<p>Women can expect their <a href="https://www.bmj.com/content/371/bmj.m3966">fertility to return to their baseline</a> “natural” level around three cycles after coming off the pill. That being said, you can definitely get pregnant as soon as you come off the pill. Being on the pill does not impact long-term fertility, even if it was taken for many years, so there’s no medical need to take a “break” from the pill to “normalise” things for the body.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-women-dont-need-to-take-a-break-from-the-pill-every-couple-of-years-87940">No, women don't need to 'take a break' from the pill every couple of years</a>
</strong>
</em>
</p>
<hr>
<p><strong>Underlying medical issues</strong> </p>
<p>For some women, coming off the pill can reveal problems the pill has been masking. For women with endometriosis, the pill commonly reduces their symptoms of painful periods, cramping, heavy bleeding and painful sex - and suppresses growth of the endometrial tissue in areas other than inside the uterus, where it belongs. Coming off the pill can cause a ramping up in period and pelvic pain. For women with a history of polycystic ovarian syndrome, periods are likely to return to being irregular once coming off the pill.</p>
<p><strong>Acne</strong> </p>
<p>For women who experience hormonally driven acne (commonly seen around the jawline and which fluctuates with the period cycle), acne can flare after coming off the pill. Getting older or lifestyle changes can impact this though, so it’s not a given acne will return.</p>
<p><strong>Mental health</strong> </p>
<p>There is <a href="https://www.nps.org.au/australian-prescriber/articles/hormonal-contraception-and-mood-disorders">growing evidence</a> the hormones in the pill can bring on or worsen depression for some women, and is one of the <a href="https://www.bmj.com/content/bmj/3/5773/495.full.pdf">most common reasons</a> for stopping the pill. However, for women who experience depressive symptoms in the week leading up to their period (a condition known as premenstrual dysphoric disorder) taking the pill stabilises the mood and <a href="https://www.nps.org.au/australian-prescriber/articles/hormonal-contraception-and-mood-disorders">works as an antidepressant</a>. It goes without saying then that women coming off the pill can see changes to their mood or anxiety levels, and it’s good to keep your mental health care provider in the loop.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-choose-the-right-contraceptive-pill-for-you-87614">How to choose the right contraceptive pill for you</a>
</strong>
</em>
</p>
<hr>
<h2>5 things to do before coming off the pill</h2>
<ul>
<li>talk to your GP or other health professionals beforehand, particularly if you have had heavy periods, painful periods or other issues in the past. If you’re not happy with your particular type of pill, know there are other options for contraception including other contraceptive pills which may not cause the same side effects</li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman against a wall closing her eyes and smiling" src="https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=373&fit=crop&dpr=1 600w, https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=373&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=373&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=469&fit=crop&dpr=1 754w, https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=469&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/471792/original/file-20220630-13-dvkid7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=469&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If you’re not happy with your particular type of pill, know there are other options for contraception.</span>
<span class="attribution"><span class="source">Unsplash/Prince Akashi</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<ul>
<li><p>have a plan for alternative contraception if you’re likely to be at risk of pregnancy and want to avoid it. If you have a regular partner, you might wish to have a conversation with them and discuss other options</p></li>
<li><p>consider monitoring and writing down your cycle and symptoms (heaviness and painfulness of periods, mood and anxiety) for 2–3 months before coming off the pill and afterwards. This can help you and your doctor recognise if coming off the pill uncovers some unexpected issues. Seek medical advice early if you are having heavy or painful periods</p></li>
<li><p>try to choose a time when life isn’t too stressful or chaotic, if possible. This will help you to work out if your symptoms are related to hormones, life in general - or both!</p></li>
<li><p>if you’re coming off the pill to prepare to conceive, it’s a good opportunity to book in for a prenatal check up. This can include talking about preparing yourself physically and mentally, supplements, and doing some blood tests to check for immunity against some viruses.</p></li>
</ul><img src="https://counter.theconversation.com/content/183367/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Phoebe Holdenson Kimura does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you’re preparing to come off the pill, it’s hard to know what to expect, particularly if you’ve been on it for a long time.Phoebe Holdenson Kimura, Lecturer and GP, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1795362022-05-24T12:45:52Z2022-05-24T12:45:52ZProtestants and the pill: How US Christians helped make birth control mainstream<figure><img src="https://images.theconversation.com/files/464873/original/file-20220523-42302-xv0uq2.jpg?ixlib=rb-1.1.0&rect=22%2C7%2C999%2C723&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protestant Christians have been debating -- and more often than not, supporting -- modern contraceptives since they first appeared.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-government-and-doctors-have-decided-the-10-million-news-photo/514867588?adppopup=true">Bettmann/Bettman via Getty Images</a></span></figcaption></figure><p>Since the Supreme Court overturned Roe v. Wade, many Christians have celebrated the prospect of an America where abortion is someday <a href="https://religionnews.com/2022/05/19/as-roes-potential-fall-nears-abortion-abolitionists-turn-on-pro-life-elites-sbc-tom-ascol-women-murder-criminal/">banned entirely</a>.</p>
<p>Meanwhile, other conservative Christians have been working on a related target: <a href="https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/05/19/some-states-already-are-targeting-birth-control">limiting access to some contraceptives</a>.</p>
<p>In July 2020, when <a href="https://www.supremecourt.gov/opinions/19pdf/19-431_5i36.pdf">the Supreme Court</a> ruled that organizations with “sincerely held religious or moral objection” are not obligated to provide contraceptive coverage to their employees, many conservative Christians <a href="https://ministrywatch.com/supreme-court-rules-in-favor-of-little-sisters-of-the-poor/">applauded</a>. Six years before, the evangelical owners of crafting chain Hobby Lobby took their objections to covering the IUD in their health insurance plans all the way to the Supreme Court. Hobby Lobby argued – incorrectly, according to most <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2017/11/long-acting-reversible-contraception-implants-and-intrauterine-devices#:%7E:text=Copper%20Intrauterine%20Device&text=The%20available%20evidence%20supports%20that,which%20it%20remains%20highly%20effective.">medical authorities</a> – that it was <a href="https://www.theatlantic.com/health/archive/2014/03/heres-why-hobby-lobby-thinks-iuds-are-like-abortions/284382/">a form of abortion</a>, and therefore they should not have to cover employees’ health insurance for it. The justices sided with the chain’s owners.</p>
<p>Yet as access to both abortion and contraception <a href="https://www.today.com/health/womens-health/overturning-roe-v-wade-threaten-birth-control-access-rcna27092">comes under threat</a>, the vast majority of Protestants <a href="https://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf">use or have used</a> some form of contraception. Their actions are supported by almost 100 years of pastoral advocacy on the issue. In my work as <a href="https://www.colorado.edu/wgst/samira-mehta">a scholar of religous studies, gender and sexuality</a>, I have researched the Protestant leaders who campaigned to make contraception respectable, and therefore widely acceptable, in the mid-20th century. </p>
<p>History, I have found, provides a different story about the relationship between Protestants and birth control.</p>
<h2>‘Responsible parenthood’</h2>
<p>As new contraceptive options emerged in the first two-thirds of the 20th century, from the <a href="https://www.popsci.com/story/science/contraception-diaphragm-history/">diaphragm</a> to the birth control pill, Christian leaders <a href="https://doi.org/10.2979/amerreli.1.2.02">wrestled with what to think</a>. Many came to see birth control as a moral good that would allow married couples to have satisfying sex lives, while protecting women from the health risks of frequent pregnancies. They hoped it could ensure that couples would not have more children than they could care for, emotionally and economically.</p>
<figure class="align-center ">
<img alt="A black and white photograph shows women with baby carriages lined up on a street." src="https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464874/original/file-20220523-31005-tpf96t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Women with children stand outside Sanger Clinic, the first birth control clinic in United States, in Brooklyn, New York in 1916.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/women-with-children-outside-sanger-clinic-first-birth-news-photo/1347202932?adppopup=true">Circa Images/GHI/Universal History Archive/Universal Images Group via Getty Images</a></span>
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</figure>
<p>They looked inward, considering the consequences of birth control for their own communities, and hoped that “planned” or “responsible” sex would create healthy families and decrease divorce. They also looked outward, thinking about birth control’s wider implications, at a time of widespread concern that the global population <a href="https://www.smithsonianmag.com/innovation/book-incited-worldwide-fear-overpopulation-180967499/">was rising too quickly to handle</a>.</p>
<p>By the time <a href="https://theconversation.com/freer-sex-and-family-planning-a-short-history-of-the-contraceptive-pill-92282">the pill</a> came on the market in the 1960s, liberal and even some conservative Protestants were advocating for birth control <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">using new theological ideas about “responsible parenthood</a>.”</p>
<p>“Responsible parenthood” reframed debates about family size around “Christian duty.” To be responsible in parenting was not only to avoid having more children than you could afford, nurture and educate. It also meant considering responsibilities outside the home toward churches, society and humanity.</p>
<p>Protestant leaders supporting contraception argued that the best kind of family was a father with a steady job and a homemaker mother, and that birth control could <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">encourage this model</a>, because smaller families could maintain a comfortable lifestyle on one income. They also hoped that contraception would help couples stay together by allowing them to have satisfying sex lives.</p>
<p>Multiple denominations <a href="https://doi.org/10.2307/1190751">endorsed birth control</a>. <a href="https://www.nytimes.com/1958/08/26/archives/lambeth-bishops-for-birth-control-family-planning-described-by.html">In 1958</a>, for example, the Anglican Communion stated that family planning was a “primary obligation of Christian marriage,” and chastised parents “who carelessly and improvidently bring children into the world, trusting in an unknown future or a generous society to care for them.” </p>
<h2>The big picture</h2>
<p>Religious leaders’ support for “responsible parenthood” was not just about deliberately creating the kind of Christian families they approved of. It was also about heading off the horrors of <a href="https://www.nytimes.com/2015/06/01/us/the-unrealized-horrors-of-population-explosion.html">population explosion</a> – a fear very much front of mind in mid-century America.</p>
<p>In the middle of the 20th century, with increased access to vaccines and antibiotics, more children were living to adulthood and life expectancies were rising. Protestant leaders feared this so-called <a href="https://www.smithsonianmag.com/innovation/book-incited-worldwide-fear-overpopulation-180967499/">population bomb</a> would outstrip the Earth’s food supply, leading to famine and war. </p>
<p>In 1954, when the global population stood at <a href="https://www.eea.europa.eu/data-and-maps/daviz/data-visualization-40#tab-chart_1">about 2.5 billion</a>, Rev. Harry Emerson Fosdick, <a href="https://www.christianitytoday.com/history/people/pastorsandpreachers/harry-emerson-fosdick.html">one of the most prominent Protestant voices of the age</a>, framed overpopulation as one of the world’s “basic problems,” and the birth control pill, which was then being developed, as the best potential solution.</p>
<p>Richard Fagley, a minister who served on the World Council of Church’s Commission of the Churches on International Affairs, <a href="https://books.google.com/books/about/The_Population_Explosion_and_Christian_R.html?id=jhbaAAAAMAAJ">argued that</a> in family planning, science had provided Christians with a new venue <a href="https://www.universitypressscholarship.com/view/10.5149/northcarolina/9781469636269.001.0001/upso-9781469636269-chapter-009">for moral responsibility</a>. Medical knowledge, Fagley wrote, is “a liberating gift from God, to be used to the glory of God, in accordance with his will for men.”</p>
<p>These “responsible parenthood” ideas held that religious couples had a responsibility to be good stewards of the earth by not having more children than the planet could support. In the context of marriage, contraception was viewed as moral, shoring up a particular form of Christian values.</p>
<h2>Yesterday’s arguments</h2>
<p>These ideas about “good” and “bad” families often rested on assumptions about race and gender that reproductive rights advocates find troubling today. </p>
<p>Early in the 20th century, predominantly white, Protestant clergy were very interested in increasing access to contraception for the poor, who were often Catholic or Jewish immigrants <a href="https://www.ucpress.edu/book/9780520303218/birth-control-battles">or people of color</a>. Some scholars have argued that early support for contraception was predominantly about eugenics, particularly before World War II. Among some white leaders, there was concern about so-called <a href="https://doi.org/10.2307/204082">race suicide</a>: the racist fear that “they” would be overwhelmed.</p>
<p>Apart from <a href="https://doi.org/10.1017/jme.2021.54">some eugenicists, however</a>, most of these clergy wanted to give people access to contraception in order to create “healthy” families, regardless of income level. Yet many were unable or unwilling to see how they were promoting a narrow view of the ideal family, and how that marginalized poor communities and people of color – themes I am studying in my current book project.</p>
<p>Moreover, many proponents were advocating for women’s health, but not reproductive freedom. Their priority was setting women up for <a href="https://uncpress.org/book/9781469636269/devotions-and-desires/">success to attain their ideal</a> of the middle-class, Christian motherhood. With fewer children, some hoped, families would be able to get by on just a husband’s salary, meaning more women at home raising children.</p>
<h2>A battle won – and lost?</h2>
<p>Over the decades, Protestant leaders have, in large part, disappeared from pro-birth control arguments.</p>
<p>There are many reasons. Mid-century agricultural technologies reduced fears of overpopulation – which have only recently been <a href="https://theconversation.com/curb-population-growth-to-tackle-climate-change-now-thats-a-tough-ask-153382">reawoken by the climate crisis</a>. Meanwhile, mainline Protestant churches, and their public influence, <a href="https://www.pewresearch.org/fact-tank/2015/05/18/mainline-protestants-make-up-shrinking-number-of-u-s-adults/#:%7E:text=Pew%20Research%20Center's%202014%20Religious,Study%20was%20conducted%20in%202007.">are shrinking</a>. Conservative leaders eventually grew concerned that birth control would lead to more working women, not fewer. And since the 1970s, evangelicals <a href="https://www.npr.org/2019/06/20/734303135/throughline-traces-evangelicals-history-on-the-abortion-issue">have grown increasingly opposed</a> to abortion, which was increasingly linked to birth control through the broad term “family planning.”</p>
<p>In other words, since the “population bomb” was no longer ticking, contraception no longer seemed like such an urgent necessity – and some of its other implications troubled conservatives, breaking an almost pan-Protestant alliance.</p>
<p>Meanwhile, liberal Protestants had so embraced contraception that they no longer viewed it as turf that needed defending. Today, 99% of American girls and women between the ages of 15 and 44 who have ever had sex <a href="https://www.cdc.gov/nchs/nsfg/key_statistics/c.htm#contraception">use or have used a contraceptive method</a>. Reproductive rights advocates turned their attention to abortion rights – largely leaving religious views on birth control to their opponents.</p><img src="https://counter.theconversation.com/content/179536/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samira Mehta does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Conservative Christians have cheered restrictions on some birth control. But many decades ago, Christian leaders’ support helped contraceptives become acceptable in the first place.Samira Mehta, Associate Professor of Women and Gender Studies & Jewish Studies, University of Colorado BoulderLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1829642022-05-17T10:01:42Z2022-05-17T10:01:42ZBirth control: what to expect if you choose to come off it<figure><img src="https://images.theconversation.com/files/463588/original/file-20220517-15-x18rn5.jpg?ixlib=rb-1.1.0&rect=35%2C11%2C7904%2C5285&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Your period will return quickly after you stop the pill.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-taking-birth-control-pills-2083070260">antoniodiaz/ Shutterstock</a></span></figcaption></figure><p>Deciding to stop using your regular birth control is a big decision. There are a number of reasons why you might be considering this – whether that’s to have a baby, or because of negative side effects you might be experiencing (such as mood swings). But while there’s plenty of discussion about what to expect when starting birth control, there’s less information out there about what to expect when you decide to quit. </p>
<p>One of the biggest things to consider if you do stop using your regular birth control is the possibility of <a href="https://www.nice.org.uk/guidance/cg156/chapter/Recommendations#initial-advice-to-people-concerned-about-delays-in-conceptio">becoming pregnant</a>. If you’re trying to avoid this, using a back-up contraceptive method is important. </p>
<p>But some women may also experience changes to their periods, skin or mood when they come off the pill and their natural cycle returns. This is because most contraceptive methods contain hormones – typically oestrogen and progesterone – which suppress the body’s normal hormonal changes. This not only prevents pregnancy, but may also have other effects – such as reducing period pain or affecting mood. </p>
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<img alt="Quarter life, a series by The Conversation" src="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451343/original/file-20220310-13-1bj6csd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><strong><a href="https://theconversation.com/uk/topics/quarter-life-117947?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">This article is part of Quarter Life</a></strong>, a series about issues affecting those of us in our twenties and thirties. From the challenges of beginning a career and taking care of our mental health, to the excitement of starting a family, adopting a pet or just making friends as an adult. The articles in this series explore the questions and bring answers as we navigate this turbulent period of life.</em></p>
<p><em>You may be interested in:</em></p>
<p><em><a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a></em></p>
<p><em><a href="https://theconversation.com/ivf-add-ons-why-you-should-be-cautious-of-these-expensive-procedures-if-youre-trying-to-conceive-180198?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">IVF add-ons: why you should be cautious of these expensive procedures if you’re trying to conceive</a></em></p>
<p><em><a href="https://theconversation.com/we-wont-have-a-male-contraceptive-until-we-change-our-understanding-of-risk-68375?utm_source=TCUK&utm_medium=linkback&utm_campaign=UK+YP2022&utm_content=InArticleTop">We won’t have a male contraceptive until we change our understanding of risk</a></em></p>
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<h2>The pill</h2>
<p>The <a href="https://digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2020-21/data-tables">most common method</a> of birth control used by women in the UK is the pill. This includes both the combined pill (which contains both oestrogen and progestogen) and the progestogen-only pill (often called the “mini pill”). </p>
<p>If you decide you want to stop using the pill, it’s typically best to wait until <a href="https://www.nhs.uk/conditions/contraception/miss-combined-pill/">the end of a packet</a>. This will <a href="https://www.fsrh.org/standards-and-guidance/documents/fsrh-ceu-switching-document-feb-2019">lower the risk of becoming pregnant</a> from intercourse that took place just before stopping the pill. When using a combined pill, it’s safe to have sex during the pill free break, but only if you start the next packet on the correct day and take pills for at least the next seven days. That is why stopping in the middle of a packet is risky in terms of pregnancy.</p>
<p>The biggest change you’ll experience when stopping is the return of your normal menstrual cycle. Since the combined pill typically makes <a href="https://www.nhs.uk/conditions/contraception/combined-contraceptive-pill/">periods lighter, less painful and more predictable</a>, you may find your periods are heavier and more painful in comparison when you stop the pill. Your periods will also return to their regular pattern (which for some may have been irregular). People who experienced mid-cycle pain (during ovulation) or pre-menstrual syndrome before starting the pill may also see these return.</p>
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<strong>
Read more:
<a href="https://theconversation.com/contraception-the-way-you-take-the-pill-has-more-to-do-with-the-pope-than-your-health-109392">Contraception: the way you take the pill has more to do with the pope than your health</a>
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<p>If you were using the combined pill to improve acne or manage certain conditions (such as polycystic ovary disease) you will likely find these benefits are lost once you stop. </p>
<p>But if you were someone who took the mini pill, you may find your experience is slightly different when you stop. The <a href="https://www.nhs.uk/conditions/contraception/the-pill-progestogen-only">progestogen-only pill</a> does not provide the regularity of periods that the combined pill usually does – with many women often having irregular bleeding (usually light but unpredictable) while taking it. So when you stop the mini pill, your period will likely return to its natural pattern, which may be more regular and predictable. </p>
<p>Since progestogen has various side effects for some women – such as causing acne, mood changes or low libido – stopping both the combined and mini pill may <a href="https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-pop-mar-2015">improve all of these</a>. </p>
<p>It’s also important to note that your periods and your fertility return very quickly after stopping the pill and you could <a href="https://www.nhs.uk/conditions/contraception/when-periods-after-stopping-pill/">become pregnant</a> within weeks or even days of stopping. So use a back-up method immediately after stopping the pill if this is something you want to avoid. </p>
<h2>Longer-acting contraceptives</h2>
<p>Longer-acting hormonal contraceptive methods – such as the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-implant">implant</a>, <a href="https://www.nhs.uk/conditions/contraception/ius-intrauterine-system">hormonal intrauterine system</a> (IUS) and the <a href="https://www.nhs.uk/conditions/contraception/contraceptive-injection">injection</a> – have similar effects on the menstrual cycle as the pill. This may include making periods lighter but more unpredictable, or even the absence of periods. </p>
<figure class="align-center ">
<img alt="A pair of hands wearing blue surgical gloves holds a copper IUD." src="https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463589/original/file-20220517-13-npn8uz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Fertility will return to normal after having your IUD or IUS removed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-holding-tshaped-intrauterine-birth-control-2074498042">New Africa/ Shutterstock</a></span>
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<p>If you have your implant or IUS removed, your menstrual cycle will return to its previous pattern within weeks. Your fertility will also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055351/">return to normal</a> within days or weeks.</p>
<p>But with the injection, you might not have a period for several months after stopping – and the return of fertility can also be delayed <a href="https://www.fsrh.org/standards-and-guidance/documents/cec-ceu-guidance-young-people-mar-2010/fsrh-guideline-contraception-young-people-may-2019.pdf">by a few months</a>. This is most likely because of the high dose of hormone in the injection, and how well it suppresses the natural cycle. However, most women typically get their period again <a href="https://www.nhs.uk/conditions/contraception/contraceptive-injection/">within a year</a> of stopping the injection, and these periods are as regular and heavy (or light) as before.</p>
<p>If you use the copper <a href="https://www.nhs.uk/conditions/contraception/iud-coil/">intrauterine device</a> (IUD), this does not contain any hormones. Though it’s long-acting and extremely effective against pregnancy, some women experience heavier and longer periods when using this method. Fertility returns immediately after having the IUD removed, so it’s important for women who don’t want to become pregnant to use back-up contraception. It’s also advised women with an IUD don’t have unprotected <a href="https://www.nhs.uk/conditions/contraception/iud-coil/">sex for a week before removal</a> because fertility returns so quickly. </p>
<p>You might be concerned about contraception having a long term effect on your periods or your fertility, but happily <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055351/">all the evidence</a> points to this not being the case. Some women may find they experience a slight delay in the return of their periods after stopping any form of hormonal birth control (though it’s most common with the injection). This is because it can take a few weeks for the body’s natural hormonal cycle to re-establish itself. This is not a cause for concern unless it goes on for many months. </p>
<p>The decision to stop using birth control is an extremely personal one, and will be influenced by whether you want to have a baby, your relationship and many other factors. Apart from sterilisation, all modern contraceptive methods are designed to be fully reversible. While you might notice some effects after stopping, these are typically due to the return of the natural rhythms of the menstrual cycle.</p><img src="https://counter.theconversation.com/content/182964/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has received funding from Bayer PLC and Natural Cycles. </span></em></p>Any effects you might notice after stopping birth control are typically due to the return of your natural menstrual cycle.Susan Walker, Reader in Contraception, Reproductive and Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1798312022-05-16T01:49:44Z2022-05-16T01:49:44ZConsidering an IUD but worried about pain during insertion? Here’s what to expect<figure><img src="https://images.theconversation.com/files/459989/original/file-20220427-21-y2d8js.jpg?ixlib=rb-1.1.0&rect=29%2C0%2C4962%2C3335&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Intrauterine devices (IUDs) are small T-shaped plastic devices containing either copper or a low dose of progestogen hormone. Lasting five to ten years, they provide <a href="https://www.nejm.org/doi/full/10.1056/nejmoa1110855">highly effective contraception</a> and are chosen by increasing numbers of <a href="https://srh.bmj.com/content/familyplanning/early/2020/01/21/bmjsrh-2019-200474.full.pdf">users of all ages</a> from adolescence to perimenopause. </p>
<p>The main device sold in Australia is the Mirena Hormonal IUD, which is also used to manage heavy periods and can be part of <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2009-PI-01235-3&d=20220427172310101">hormonal menopause therapy</a>. While insertion is usually well tolerated, it can also cause discomfort and pain, or severe pain for a small number of women. So it’s important to know what to expect during and after the procedure, and what pain relief options are available. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CdaD-c8rOCo/?igshid=YmMyMTA2M2Y=","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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<strong>
Read more:
<a href="https://theconversation.com/dont-want-to-take-a-contraceptive-pill-every-day-these-are-the-long-acting-alternatives-92116">Don't want to take a contraceptive pill every day? These are the long-acting alternatives</a>
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<h2>What happens during an IUD insertion procedure?</h2>
<p>The procedure lasts about ten minutes. Once positioned on the clinic bed, the doctor (either a GP or gynaecologist) or nurse performs what’s called a bimanual examination by inserting gloved fingers into the vagina while the other hand is on the lower abdomen to check the size, position and shape of the uterus. </p>
<p>An instrument called a speculum is then inserted into the vagina to allow the cervix to be seen. This is usually not uncomfortable or painful, though some conditions may make it more difficult, including vaginismus (an involuntary tightening of the pelvic muscles during vaginal penetration) and vaginal dryness. These can usually be treated before insertion to reduce discomfort. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Gloved hand holding plastic speculum" src="https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459991/original/file-20220427-14-cvbzyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A speculum allows the vagina to be opened so the cervix can be seen.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The speculum is generally in place for around two to five minutes. To ease the insertion, most practitioners place an instrument called a tenaculum on the cervix to steady the uterus and straighten the cervix. This can sometimes cause a quite sharp pain, which usually settles in a few seconds. </p>
<p>A small fine instrument called a sound is passed through the cervix to measure the length of the uterus, and the IUD is then placed at the top of the uterus. This part of the procedure can cause cramping pain and make some people feel a bit lightheaded. </p>
<p>Lastly, the threads attached to the bottom of the IUD are shortened, so they gently wind around the cervix. The speculum is removed and the IUD insertion is complete.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand holding a copper IUD" src="https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459990/original/file-20220427-20-zf6nc5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The IUD has threads at the end to aid removal.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Why do some people experience more pain than others?</h2>
<p>Despite many online reports of severe pain from insertion, a <a href="https://pubmed.ncbi.nlm.nih.gov/26378938/">study</a> (with partial funding from the manufacturers) which surveyed more than 1,800 women from 11 European countries having a hormonal IUD inserted found the majority experienced mild or moderate pain. Severe pain was experienced by 15.5% of those who had never given birth, 4.5% of those who had caesarean sections and 1.9% of those who had vaginal deliveries.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1519001700714967041"}"></div></p>
<p>Overall, the pain during insertion of a Mirena IUD in 413 women in Brazil, of whom one-third had never given birth, <a href="https://www.tandfonline.com/doi/abs/10.1080/13625187.2021.1925882?journalCode=iejc20">was rated at around</a> 4.4 to 6.6 out of ten, where ten is the worst pain possible. Apart from having given birth, other predictors of experiencing greater levels of pain include <a href="https://srh.bmj.com/content/48/e1/e31">having painful periods</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/13625187.2019.1610872?journalCode=iejc20">fear of pain</a>, although people without risk factors may nevertheless experience pain and people with risk factors may remain free of pain. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/for-women-even-a-small-co-pay-for-contraception-can-be-a-big-deal-41877">For women, even a small co-pay for contraception can be a big deal</a>
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<p>There is also <a href="https://pubmed.ncbi.nlm.nih.gov/22222193/">some evidence</a> the newer hormonal IUD (brand name “Kyleena”), which is slightly smaller than the Mirena IUD, is easier to insert and causes less pain. A <a href="https://pubmed.ncbi.nlm.nih.gov/32223466/">recent community study</a> of Kyleena insertion showed that around two-thirds of those who had never given birth experienced no or mild pain while around 8% experienced severe pain.</p>
<h2>What pain relief options are available?</h2>
<p>Evidence-based recommendations for reducing insertion pain are limited but more research is underway. Most practitioners recommend taking an anti-inflammatory medication an hour before insertion. <a href="https://pubmed.ncbi.nlm.nih.gov/22766124/">Stronger pain relief may be considered</a> for those with particularly painful periods, a history of endometriosis or severe worries about the procedure.</p>
<p>An anti-nausea tablet can be helpful if there is vomiting with menstruation. Application of a local anaesthetic spray or cream to the cervix can <a href="https://www.sciencedirect.com/science/article/abs/pii/S0015028218322076">decrease insertion pain</a>, although this will add to the cost and time of the procedure and may not be offered by all practitioners. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-women-arent-getting-long-acting-contraception-when-they-need-it-most-48460">Why women aren't getting long-acting contraception when they need it most</a>
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<p>The “green whistle” Penthrox inhaler, an anaesthetic drug used in ambulances for trauma-related pain, is also being trialled.</p>
<p>Less commonly, some people choose to have their IUD inserted under twilight sedation which means staying in a day surgery or hospital for around four hours. While some family planning services offer sedation at low cost, it is not universally available due to long public hospital waiting lists or costly private clinic fees. </p>
<p>Being aware of this option and its pros and cons is important to help informed decision-making. Sedation risks, extra time off work and costs need to be balanced against the evidence that most people tolerate the procedure without sedation, experiencing mild or moderate pain. As local anaesthesia has proven benefits for IUD insertion-related pain relief, finding a practitioner who routinely offers this option can be important.</p>
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<h2>What to expect after the procedure</h2>
<p>After insertion, people are asked to stay at the clinic for around 20 minutes and while most will be able to get home themselves, it’s better to arrange to be picked up or to catch a taxi in case there is pain that is not settling. Once home, hot packs and over-the-counter analgesics such as naproxen, ibuprofen or paracetamol can be helpful, and taking it easy for a day or two is usually advised. </p>
<p>Although <a href="https://pubmed.ncbi.nlm.nih.gov/26126950/#:%7E:text=IUD%20users%20noted%20an%20adjustment,and%20continuation%20of%20an%20IUD">intermittent cramps</a> can last for a few months as the IUD “settles in”, our own clinical experience has shown this is particularly around menstruation.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurse chatting to young female on doctor's bed" src="https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459992/original/file-20220427-18-jr4pjv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Talk to your doctor or nurse about what to expect during the procedure.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>But if pain is getting worse, is not helped by simple analgesics, or accompanied by a smelly or profuse vaginal discharge or fever, it is essential to seek medical advice. </p>
<p>An ultrasound would be organised and if the IUD is shown to be in the correct position, and there is no evidence of an infection, it would become a personal choice whether or not, or for how long, to persist. Around 11.5% of Mirena users and 17.5% of copper IUD users who have the IUD removed early <a href="https://pubmed.ncbi.nlm.nih.gov/26259905/#:%7E:text=Three%2Dyear%20continuation%20rates%20were,001">cited pain</a>) as part of their decision for premature IUD removal.</p>
<h2>Knowledge is power</h2>
<p>Seeking out credible information about the IUD insertion process from family planning websites, and talking to your doctor or nurse about what to expect during the procedure, including the available pain relief options, is essential. This can help overcome the anxiety that may come about from relying solely on online scare stories.</p><img src="https://counter.theconversation.com/content/179831/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Bateson has attended advisory committees for Bayer and provided professional training for clinicians which have been sponsored by Bayer as part of her role as Medical Director of Family Planning NSW. She has never received any personal remuneration for these activities.</span></em></p><p class="fine-print"><em><span>Kathleen McNamee's employer, Sexual Health Victoria, has receives funding from Bayer Australia and New Zealand to train and support doctors and nurse in IUD insertion. She has not received any personal remuneration for these activities.</span></em></p>More women are using long acting reversible contraceptives. However some worry about pain on insertion.Deborah Bateson, Clinical Associate Professor, Discipline of Obstetrics, Gynaecology and Neonatology, University of SydneyKathleen McNamee, Adjunct Senior Lecturer, Obstetrics & Gynaecology, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1641952021-07-14T15:03:20Z2021-07-14T15:03:20ZBirth control continues to fail women – so why has nothing changed?<figure><img src="https://images.theconversation.com/files/411195/original/file-20210714-25-1s4vtc6.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5607%2C3724&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unpleasant side effects from contraceptives are experienced by many women.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gynecology-consultation-181677890">Image Point Fr/ Shutterstock</a></span></figcaption></figure><p>The hunt for a “<a href="https://sitn.hms.harvard.edu/flash/2021/a-potential-male-oral-birth-control-pill-may-be-on-the-horizon/">male birth control pill</a>” is a topic that often grabs attention. But so far no products have been licensed for use, either because they haven’t been effective enough, or because of <a href="https://www.newscientist.com/article/2110729-male-contraceptive-injection-works-but-side-effects-halt-trial/">negative side effects</a> – including depression, mood disorders and acne – that halted trials.</p>
<p>Current contraceptive options for men are <a href="https://pubmed.ncbi.nlm.nih.gov/10785217/">limited</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254803/">not always effective</a> – so it’s no wonder research continues in this area. But, while this is important, it’s critical that this isn’t at the expense of improving contraceptives currently available for women.</p>
<p>Since the female birth control pill first <a href="https://www.theguardian.com/society/2007/sep/12/health.medicineandhealth">became available</a> in the 1960s, it has allowed many to control their own fertility and manage conditions such as dysmenorrhoea (painful periods), non-menstrual pelvic pain and heavy menstrual bleeding. </p>
<p>But despite these benefits, birth control options are still failing women. This is largely because of the <a href="https://www.bbc.com/future/article/20180823-women-speak-about-side-effects-of-the-birth-control-pill">unpleasant side effects</a> many people experience when using them – which in some cases severely <a href="https://www.fertstert.org/article/S0015-0282(17)30247-9/fulltext">decreases quality of life</a>.</p>
<p>Women often have to put up with side effects when using contraceptives, such as irregular bleeding, bloating and headaches. In some cases, these side effects are more serious, and may include high blood pressure, <a href="https://www.bmj.com/content/373/bmj.n1159/rr-4">blood clots</a> and stroke. Research has also found a link between the pill and increased <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">risk of depression</a>, as well as <a href="https://pubmed.ncbi.nlm.nih.gov/16913282/">decreased sexual desire and libido</a>. </p>
<p><a href="https://apps.who.int/iris/handle/10665/75429">Side effects</a> are the reason around one-third of women stop their contraception in the first year of use. Perhaps as a result, use of the contraceptive pill in the UK <a href="https://digital.nhs.uk/data-and-information/publications/statistical/sexual-and-reproductive-health-services/2018-19">decreased from 45% in 2015 to 39% in 2019</a>.</p>
<p>It isn’t just the pill that needs improvement. Long-acting reversible contraceptives – such as inter-uterine devices (IUDs) and contraceptive implants – are used by around <a href="https://pubmed.ncbi.nlm.nih.gov/29972356/">12% of women</a> in the UK, but also come with their own side effects and disadvantages. </p>
<p>Like the pill, hormonal IUDs (a small device that is placed in the uterus, where it releases hormones) can <a href="https://pubmed.ncbi.nlm.nih.gov/24695563/">cause side effects</a> such as irregular or missing periods, headaches, nausea, hair loss, depression, and decreased libido. Even <a href="https://pubmed.ncbi.nlm.nih.gov/19341847/">non-hormonal IUDs</a> (such as the copper IUD) can cause heavier periods, longer menstrual cycles and increased pain – causing many women to have them removed early. Many women also report experiencing <a href="https://www.bbc.co.uk/news/health-57551641">painful IUD fittings</a> – often <a href="https://www.fsrh.org/standards-and-guidance/fsrh-guidelines-and-statements/method-specific/intrauterine-contaception/">without the use</a> of local anaesthetic gels. </p>
<figure class="align-center ">
<img alt="An intrauterine device." src="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411196/original/file-20210714-25-ya98ot.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Both hormonal and non-hormonal IUDs can cause side effects.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/iud-174193595">Image Point Fr/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Finding a contraceptive method that works usually involves a lot of <a href="https://sexualhealthdorset.org/contraception">trial and error</a>. This is partly because clinicians don’t have access to large-scale and detailed data which could help them predict which method will work best for different people. The presence of side effects and their severity differs between women, depending on their sensitivity to hormonal changes – and <a href="https://www.sciencedaily.com/releases/2020/05/200512134532.htm">potentially because of genetics</a>.</p>
<h2>Need for improvement</h2>
<p>There’s a clear need for large-scale clinical trials into new and existing forms of birth control. Yet despite this, little investment is actually put into making this happen, and priority tends to be given to other areas of research. For example, between 2017 and 2020, there were only 23 <a href="https://clinicaltrials.gov/ct2/results?cond=contraception&strd_s=01%2F01%2F2017&strd_e=07%2F12%2F2020&recrs=b&recrs=a&recrs=f&recrs=d&recrs=g&recrs=h&recrs=e&recrs=i&age_v=&age=1&gndr=Female&type=&rslt=&phase=4&phase=0&phase=1&phase=2&phase=3&fund=2&Search=Apply">industry-funded clinical trials</a> into contraceptives, compared to <a href="https://pharmaintelligence.informa.com/resources/product-content/clinical-trials-2019-roundup">600 for cardiovascular drugs and 140 for treatment relating to eye disorders</a>. </p>
<p>Most shockingly, only 2% of the revenue made by pharmaceutical companies selling contraception goes back into <a href="https://www.bloomberg.com/news/articles/2019-08-08/better-birth-control-exists-but-big-pharma-isn-t-interested">research and development</a>. Even when methods are improved or refined, they’re often <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-018-3136-4">not available worldwide</a> due to local regulations and health systems. </p>
<p>Access to preferred contraception in the UK (such as specific brands) is also largely dependent on commissioning systems (which assesses needs, and plan purchasing and monitoring of health services in the NHS) and contraceptive budgets – which were <a href="https://www.theguardian.com/society/2020/sep/10/women-in-uk-struggling-to-access-contraception-as-result-of-underfunding">cut by 13%</a> between 2015 and 2018. </p>
<p>Such budget cuts may mean a person has to switch from a brand they’re happy with to one that doesn’t work as well for them. And though the UK has now allowed <a href="https://www.gov.uk/government/news/first-progesterone-only-contraceptive-pills-to-be-available-to-purchase-from-pharmacies">progesterone-only pills</a> to be bought over the counter without a prescription, women still have limited ways to access birth control – and the costs associated with it may be too much for some.</p>
<p>Alongside these issues of access is a continued lack of research and development into women’s contraceptives for a variety of different reasons. For one, there’s little incentive to improve them, as it has already been proved that they prevent pregnancy. In addition, funding bodies are often interested in areas of research that affect all people – not just women – so funding will be prioritised to them. Many women will also continue using birth control despite side effects because they don’t want to get pregnant – so many developers may not see improving formulations as necessary. </p>
<p>Although there’s a clear need to develop better male contraceptives, much still needs to be done to address the inequalities women currently experience when it comes to sexual and reproductive health. The <a href="https://www.gov.uk/government/consultations/womens-health-strategy-call-for-evidence/womens-health-strategy-call-for-evidence">Women’s Health Strategy</a> has recently sought to collect views on women’s health to ensure that women’s voices are at the centre of new health agendas – which will hopefully help inform policies, strategies and healthcare. There are also numerous trials ongoing seeking to <a href="https://www.nature.com/articles/d41586-020-03532-6">improve contraceptive options</a> for women.</p>
<p>But it isn’t solely up to pharmaceutical companies to bring about changes – it will be up to regulators to listen to women when assessing the effectiveness of new contraceptive methods, and clinicians, to listen to patients’ concerns and questions.</p><img src="https://counter.theconversation.com/content/164195/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bethan Swift receives funding from Mustafa Bahceci (Bahceci Health Group, Istanbul, Turkey) for her Doctor of Philosophy at the University of Oxford (2019-2022).</span></em></p><p class="fine-print"><em><span>Christian Becker currently receives research funding from the European Comission and Bayer Healthcare. Both are not related to this article.</span></em></p>Despite side effects, women continue to take contraceptives because there are no better options available.Bethan Swift, PhD candidate in Women's and Reproductive Health, University of OxfordChristian Becker, Associate Professor, Nuffield Department of Obstetrics and Gynaecology,, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1544002021-02-03T14:21:34Z2021-02-03T14:21:34ZGrey squirrels: is birth control the solution to Britain’s invasive species problem?<figure><img src="https://images.theconversation.com/files/382224/original/file-20210203-21-kb8tu8.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4020%2C2832&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/grey-squirrel-feeding-on-chestnuts-autumn-118390966">Scooperdigital/Shutterstock</a></span></figcaption></figure><p>There are thought to be 2.7 million grey squirrels in the UK, versus only 287,000 <a href="http://publications.naturalengland.org.uk/publication/5636785878597632">red squirrels</a>. The invasive greys, brought to Britain and Ireland from North America in the 1870s, are blamed for the disappearance of the native red throughout much of England and Wales, due to the squirrel pox virus they transmit and the fact that they compete for food and habitat with their smaller relatives.</p>
<p>As with the UK’s other invasive species, such as rabbits, signal crayfish and Japanese knotweed, introducing the grey squirrel has proved to be an expensive mistake. Not only do grey squirrels displace red squirrels, they strip bark from trees. <a href="https://rfs.org.uk/news/2020/1-2021/grey-squirrels-threatening-our-woodlands-to-tune-of-11bn/">A recent report</a> estimated that this could cost commercial forestry and native woodlands £1.1 billion (US$1.5 billion) over the next 40 years, including revenue lost to damaged timber, reduced carbon storage, tree replacement costs and squirrel control.</p>
<p>Despite efforts to kill grey squirrels over several decades, their populations remain large and widespread. So could <a href="https://www.bbc.co.uk/news/science-environment-55817385">government-backed plans</a> for using oral contraceptives to control their breeding be the turning point?</p>
<h2>Squirrel birth control</h2>
<p>Before we consider that question, let’s interrogate the idea that grey squirrels are bad for the environment because they damage trees. If we’re worried about carbon in the atmosphere then phasing out fossil fuels, not killing squirrels, is the top priority. And squirrels, even non-native greys, play an important role in woodlands by <a href="https://www.frontiersin.org/articles/10.3389/fevo.2020.00259/full">burying the nuts they find</a> and seeding new trees. If grey squirrels were to vanish overnight, then the natural regeneration of UK woodlands would probably slow.</p>
<p>Whether or not the damage caused by this invasive species is exaggerated, these reports inevitably encourage calls for bigger <a href="https://www.telegraph.co.uk/news/2021/01/21/royal-forestry-society-urges-grey-squirrel-cull-wake-1bn-woodland/">culls of grey squirrels</a>. Oral contraceptives might at least be a more humane alternative to live trapping and bludgeoning the animals to death.</p>
<p>Birth control has worked for keeping wildlife populations elsewhere in check. The method, which often involves injecting contraceptives, has proved successful in more than 85 species, including wild horses and elephants, according to <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0897.2011.01003.x">a 2011 review</a>. Contraceptives halved dense and destructive populations of North American <a href="https://pdfs.semanticscholar.org/7383/a4c2227392c16c8c6269fd3e91fa65c728a4.pdf?_ga=2.143665589.1480929846.1612138237-212678758.1612138237">white-tailed deer</a> in under 10 years.</p>
<p>Research into using oral contraceptives on grey squirrels in the UK has been ongoing for <a href="https://squirrelaccord.uk/squirrels/fertility_control/">several years</a>, and recent results show promise. Trials using feeders that only grey squirrels can access, baited with hazelnut spread laced with an <a href="https://www.humanesociety.org/resources/questions-and-answers-about-immunocontraception">immunocontraceptive</a> (a drug which tricks the body’s immune system into producing antibodies that interfere with reproduction, by blocking the sperm receptor sites on eggs, for example) indicate that <a href="https://squirrelaccord.uk/news/blog/fertility-research-news-from-the-field/">around 90%</a> of a local population can be treated using this method. Researchers hope this could induce infertility to such an extent that treated populations shrink substantially over time.</p>
<p>Contraceptives have their own <a href="https://conbio.onlinelibrary.wiley.com/doi/full/10.1111/csp2.171">ethical concerns</a> though. Being alive isn’t necessarily always better than being dead. We don’t really know what physiological and psychological effects an inability to breed will have on the welfare of grey squirrels.</p>
<p>It’s also important that this contraceptive doesn’t affect other species, though there are measures to ensure this. Bespoke feeding boxes that only grey squirrels can enter limit the risk to other species, in particular red squirrels, by weighting the door of the feeder so that the smaller red <a href="https://squirrelaccord.uk/news/blog/fertility-research-news-from-the-field/">cannot enter</a>. Providing the bait in a hazelnut spread, rather than nuts which squirrels may bury, prevents other animals inadvertently finding and eating the contraceptive. But what about predators? Will their fertility be threatened by eating prey dosed with contraceptives?</p>
<h2>The alternatives</h2>
<p>There are other ways to control grey squirrel populations, such as <a href="https://thebiologist.rsb.org.uk/biologist/158-biologist/features/2245-accelerating-evolution">gene drives</a>. These are altered genes that can be implanted in males and programmed to induce infertility in the genome of their female offspring. Female infertility spreads through the population as the gene drive is carried and inherited by males. Gene drives don’t carry the same risk of cross-contamination between species that contraceptives do, and they are cheaper and easier to implement.</p>
<p>But they still have a long way to go before they’re approved as a control method, as scientists worry that a gene drive could spread from invasive to native populations. Imagine a grey squirrel in the UK that had been treated with a gene drive somehow made it back into their native range in North America – it could mean their extinction.</p>
<p>Perhaps the most popular solution to the grey problem is the pine marten, a predatory mammal that is slightly larger than a ferret. Almost hunted to extinction in the UK, pine martens have made a comeback in recent years. <a href="https://royalsocietypublishing.org/doi/pdf/10.1098/rspb.2017.2603">Research suggests</a> that where martens return to woodland they reduce grey squirrel populations, while boosting the number of red squirrels. But pine martens aren’t going to colonise the entire country – and they are still predators which eat other wildlife and some domestic animals. Their return is likely to face <a href="https://www.scotlandbigpicture.com/rewilding-stories/the-return-of-the-taghan">resistance in some places</a>.</p>
<figure class="align-center ">
<img alt="A weasel-like mammal hugging a river bank to sip the water." src="https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381704/original/file-20210201-19-1s9s592.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pine martens are thought to hunt grey squirrels more readily than reds.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pine-marten-drinking-lake-forest-1798450855">Beata Farkas/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://reader.elsevier.com/reader/sd/pii/S0304380020304506?token=65D4E8A4AD5ED08A53E7A0359A31A65414B15AB18285A97E020D0CB976E7BF1A903F54EFACC860BFCCAEFAB5F95054B7">A recent study</a> suggested the most efficient way to control grey squirrels is a combination of culling and contraceptives. So no matter how effective an oral contraceptive is, culls are likely to continue. Animal welfare campaigners are <a href="https://petition.parliament.uk/petitions/562294">lobbying the government</a> to at least halt culls during the breeding season, when female grey squirrels have kits in the nest. As it stands, mothers can be killed and their offspring left to starve.</p>
<p>I’ve written <a href="https://theconversation.com/in-defence-of-the-grey-squirrel-britains-most-unpopular-invader-73983">in defence of grey squirrels</a> before, but I support controlling their populations with contraceptives. While I’d prefer nature to provide its own solution, I welcome methods of controlling so-called pest species that minimise pain and stress. Just because a species causes damage doesn’t mean that we can’t manage them with consideration for ethics and welfare.</p><img src="https://counter.theconversation.com/content/154400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jason Gilchrist does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Squirrel feeders laced with contraceptives could be used to suppress grey squirrels in the UK.Jason Gilchrist, Ecologist, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1314912020-02-24T13:19:34Z2020-02-24T13:19:34ZSocial norms stop Ethiopian girls from making safe choices about pregnancy<figure><img src="https://images.theconversation.com/files/315298/original/file-20200213-11005-1ldto3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most young, married girls in Ethiopia don't have the family planning information they need. </span> <span class="attribution"><span class="source">GettyImages</span></span></figcaption></figure><p>Despite progress in reducing the rate of adolescent pregnancy, more than <a href="https://www.unfpa.org/publications/adolescent-pregnancy">16 million</a> adolescent girls globally become parents each year. According to the World Health Organisation, 90% of these young mothers live in the global South. </p>
<p>Girls in countries with the highest adolescent fertility rates, many of which are in <a href="https://www.unfpa.org/publications/adolescent-pregnancy">sub-Saharan Africa</a>, are also the most likely to be malnourished without access to quality maternity care or safe abortions. This leads to complications and consequences that can last a lifetime. </p>
<p>Maternity is a <a href="https://apps.who.int/adolescent/second-decade/files/1612_MNCAH_HWA_Executive_Summary.pdf">leading cause</a> of disability for girls aged 15-19, according to the World Health Organisation. </p>
<p>The maternal mortality rate for girls under 16 years is around four times that of women in their early <a href="https://www.ncbi.nlm.nih.gov/pubmed/15695970">20s</a>. In low and middle-income countries, the overwhelming majority of adolescent pregnancies occur in marriage. </p>
<p>In developing countries, an <a href="http://documents.worldbank.org/curated/en/530891498511398503/pdf/116829-WP-P151842-PUBLIC-EICM-Global-Conference-Edition-June-27.pdf">estimated 75%</a> of babies born each day to girls under the age of 18 are born to those who are already married. </p>
<p>A <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">report</a> on Ethiopia released last year corroborates this. In Ethiopia <a href="https://dhsprogram.com/pubs/pdf/SR241/SR241.pdf">60%</a> of girls are married by the age of 18. This is a significant factor in the high rate of pregnancy among 15 to 19 year olds.</p>
<p>However, many adolescent girls don’t get the care they need. Free contraceptives are available in most communities in Ethiopia, but many girls lack social access because of conservative <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">cultural and religious norms</a>. A dominant norm is that girls need to give birth as quickly as possible after marriage to <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">prove their fertility</a>.</p>
<p>Adolescent girls and community health workers also <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">report</a> that service providers — contrary to their official mandate — are also unwilling to provide advice on contraceptives because of these powerful norms.</p>
<p>What this means is that young, married girls too often don’t get the family planning information they need. They also don’t get support in negotiating with their husbands and families to take control of their own fertility. </p>
<h2>What we found</h2>
<p>Our <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">research in Ethiopia</a> found that access to contraceptive information and supplies varies by region, but that cultural and gender norms are still a barrier to use of contraception even where it is made available. </p>
<p>As one 14-year-old married girl <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">explained</a>: </p>
<blockquote>
<p>I am not using (family planning) now – before I have one child. If you stay without a child for a longer time, they will tell you, you are barren. </p>
</blockquote>
<p>Our evidence highlights that these realities need to inform efforts to reduce adolescent pregnancies and improve maternal and child health.</p>
<h2>What can be done</h2>
<p>Gender and Adolescence: Global Evidence <a href="https://www.gage.odi.org">research</a>, a longitudinal research initiative in low and middle-income countries, focuses on the consequences of early motherhood and reviewed some of the strategies already in place in some regions of Ethiopia. </p>
<p>We found promising practices in Amhara, a rural area in northern Ethiopia which has historically had the lowest average age of marriage. These included the <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0470-1">expansion</a> of a health extension programme, in which the government funds training for female secondary school graduates and employs them to deliver health care in rural regions. </p>
<p>Another good example is the <a href="https://bmjopen.bmj.com/content/9/5/e025937">Women’s Development Army</a>, a government-supported initiative involving women volunteers. It spreads messages about family planning and maternal care at the grassroots level. </p>
<p>Another effective model was developed in Amhara <a href="https://www.care.org/work/health/sexual-and-reproductive-health-and-rights/what-we-do/adolescent-health/tesfa">to improve</a> relationships between young women, their husbands and in-laws, to increase their uptake of contraceptives. <a href="https://www.care-international.org/">Care International</a>, a non-profit organisation working to end poverty by empowering women and girls, did this by engaging with community gatekeepers such as religious leaders, health workers and village elders to critically reflect on gender norms and find ways to support girls’ groups.</p>
<p>These strategies have helped improve outcomes for girls in Amhara. Our report found that adolescents there were more likely to identify a form of family planning than in other study localities.</p>
<p>There’s an urgent need to scale these efforts to tackle both adolescent pregnancy and early marriage. </p>
<p>But there are still obstacles to severing the link between marriage and early motherhood. In Oromia in central Ethiopia, girls <a href="https://www.gage.odi.org/wp-content/uploads/2019/05/Adolescent-health-nutrition-and-sexual-and-reproductive-health-in-Ethiopia-1.pdf">reported</a> fears about contraceptive use. Some cited concerns that it could make them ill, cause their hair to fall out and make them permanently infertile. </p>
<p>These fears, combined with a lack of access to reliable sexual and reproductive health information, low education rates and the pervasive social norms linking adolescent marriage and early childbirth, are all driving high adolescent fertility rates. </p>
<p>Another major barrier to breaking the link between marriage and early motherhood is in situations where large families are considered economically important. This is the case in pastoralist communities such as in Afar, a north east region of the country. </p>
<p>All these dynamics underline the need to continue to address the wider set of social norms that underpin early adolescent fertility while promoting access to education and female role models who have made different life choices. This must happen alongside the expansion of adolescent-friendly sexual and reproductive health services.</p><img src="https://counter.theconversation.com/content/131491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Pincock works for the Gender and Adolescence: Global Evidence programme. She has previously received funding from UKRI.</span></em></p><p class="fine-print"><em><span>Nicola Jones, is a principal research fellow at the Overseas Development Institute and the director of the Gender and Adolescent: Global Evidence (GAGE) programme, which receives funding from the UK Department for International Development’s Research and Evaluation Division.</span></em></p>Over 60% of girls in Ethiopia are married by the age of 18. Many don’t have support in negotiating with their husbands and families to take control of their own fertility.Kate Pincock, Research Associate, Refugees Studies Centre, University of OxfordNicola Jones, Research Fellow, Overseas Development InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1015632018-08-22T11:03:54Z2018-08-22T11:03:54ZPopularity of apps like Natural Cycles highlights serious issues with contraceptives today<figure><img src="https://images.theconversation.com/files/232351/original/file-20180816-2903-ewmmvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Natural Cycles</span></span></figcaption></figure><p>Many women have made a dramatic change in their use of contraceptives of late. Specifically, use of “contraceptive apps” such as <a href="https://www.naturalcycles.com/en?campaignid=1023659502&adgroupid=50744576537&adid=289266179911&gclid=EAIaIQobChMIiKSt06eA3QIV65XtCh2d0gCFEAAYASAAEgLHYfD_BwE">Natural Cycles</a>, a smartphone app that predicts the days on which a woman is fertile and can be used for contraception (as well as planning pregnancy), is on the rise. By closely tracking a woman’s cycle and temperature, such apps designate unprotected sex safe or unsafe each day. When unsafe, the use of barrier methods of protection is advised.</p>
<p>Natural Cycles was developed by CERN scientist Elina Berglund and her husband, Raoul Scherwitzl, whose scientific background has lent the app a certain kudos. And as “the only app certified for contraception” in Europe and, as of August 10, the US, women who might otherwise be suspicious of the method, which is at the end of the day simply jazzed up natural family planning, have taken the plunge.</p>
<p>The fact that many women are spurning more “medical” kinds of contraception, such as the pill or IUD, in favour of such apps, along with discussion in some cases of their <a href="https://www.theguardian.com/society/2018/jul/21/colossally-naive-backlash-birth-control-app">failures</a>, are once again drawing public attention to the hazards of being a pre-menopausal, heterosexual, sexually active woman. The risks of contraceptives range from milder side effects to rare but potentially serious complications. These, of course, come alongside the ever present risk of unintended pregnancy through contraceptive failure.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232340/original/file-20180816-2900-16391qp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many women report side effects with the contraceptive pill, but often aren’t listened to.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/birth-control-pill-contraceptive-safe-sex-1140875126?src=GHbPGDZp7RDjsKYf-n8MFg-2-77">Suriyachan/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Understated side effects</h2>
<p>When choosing a method of contraception, women routinely have to balance the impacts of each method against its likely effectiveness. Most of <a href="https://www.tandfonline.com/doi/abs/10.1080/07399330600629468">the evidence</a> suggests that it is common for women to choose the least bad option in terms of side effects, rather than something they are really comfortable with. Consequently, it’s not surprising that a technology that promises to overcome many of these difficulties would prove to be popular.</p>
<p>Being able to control fertility is essential for women’s equality, yet the means to do this are currently all imperfect. Side effects are a common experience and are a major cause of women stopping using particular birth control methods. In contraceptive consultations, the frequency and severity of side effects and other more serious health risks are often understated. </p>
<p><a href="https://broadly.vice.com/en_us/article/kzeazz/the-racist-and-sexist-history-of-keeping-birth-control-side-effects-secret">Research</a> suggests that health professionals seek to avoid mentioning issues they believe would cause undue concerns. This reluctance to disclose may be linked to historic ideas that women are not fully capable of rational decision making. The assumption that women are not to be trusted with contraception is most clearly seen in the promotion of <a href="http://www.dchs.nhs.uk/our-services/find_services_by_topic/different_types_of_larc">long-acting reversible contraception</a> (LARC): the injection, implant, and hormonal and copper coils. The <a href="https://www.tandfonline.com/doi/abs/10.1016/S0968-8080(13)41688-9">evidence</a> shows that some women who encounter difficulties sometimes struggle to get health professionals to remove their LARC. Women are expected to put up with side effects rather than taking a bigger risk of unintended pregnancy.</p>
<h2>A perfect woman</h2>
<p>Culturally speaking, unintended pregnancies are usually frowned upon. This is particularly the case for younger women and those in marginalised circumstances. This denigration links to ideas about irresponsibility more generally. Popular stereotypes of “feckless” families who have babies for benefits are commonplace, but are rarely accurate. In the US for example, the idea of the “welfare queen” has been shown <a href="https://www.theatlantic.com/business/archive/2016/09/welfare-queen-myth/501470/">to be false</a>. </p>
<p>In the UK, it is <a href="https://theconversation.com/welcome-to-the-uk-land-of-the-two-child-policy-44756">government policy</a> to limit the number of children claimants can receive benefits for. As in-work poverty means increasing numbers of families are reliant on <a href="https://theconversation.com/state-of-the-nation-welfare-shifts-towards-the-working-poor-39194">benefits</a>, more and more women will have their fertility judged. </p>
<p>Stereotypes of who would be or not be a “good” mother can be seen in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055778/">healthcare providers’ assumptions</a> of who would particularly benefit from LARC. It is also important to remember that the stigma surrounding abortion builds on assumptions of irresponsible women failing to successfully control their fertility. This is despite the evidence that contraceptive failure is a significant reason for <a href="https://www.bpas.org/about-our-charity/press-office/press-releases/women-cannot-control-fertility-through-contraception-alone-bpas-data-shows-1-in-4-women-having-an-abortion-were-using-most-effective-contraception/">needing abortion</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232339/original/file-20180816-2903-1f7jhui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Failed contraceptives are a major cause of unwanted pregnancy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-makes-pregnancy-test-waiting-result-1153289131?src=tN-Li7fOfp2dlUIKtYZTRA-2-8">Vadim Zakharishchev/Shutterstock</a></span>
</figcaption>
</figure>
<p>The cultural notions that women fail, rather than the fault being with contraceptive technologies, has even become standardised within health information. Many contraceptive information pages have institutionalised notions of women’s irresponsibility by including statistics on effectiveness reporting “perfect” and “typical” use. Given that “perfect” use for some methods is actually beyond women’s control (for example, the impact of a stomach upset on the pill), just showing “typical” use would ensure women were informed properly but without being judgemental. </p>
<p>Although women are largely held responsible for failure, that does not necessarily mean they are seen as responsible enough to make decisions over which birth control method to use. Although in other parts of the world, emergency hormonal contraception is available in <a href="https://www.mercurynews.com/2013/07/31/morning-after-pill-goes-on-sale-thursday-in-pharmacies-and-grocery-stores-available-to-anyone/">supermarkets</a> or even <a href="https://www.telegraph.co.uk/women/sex/should-have-morning-pill-vending-machines-every-street-corner/">vending machines</a>, in the UK and Australia, women wanting access need to have a consultation, even if this just takes place in a pharmacy. This is not necessarily to access them medically, but so they can be “advised” to avoid future “mistakes”.</p>
<h2>Gendered inequality</h2>
<p>In an age where relationships are supposed to be equal partnerships, contraception raises equality issues. To date, the “<a href="https://theconversation.com/heres-whats-on-the-horizon-for-a-male-contraceptive-pill-but-dont-hold-your-breath-92509">male pill</a>” still has not materialised, leaving men with few options. Condoms are often not seen as “proper” contraception for ongoing relationships. The protection they provide against sexually transmitted infections means that they are associated with casual partners. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/232337/original/file-20180816-2912-1d1os5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Condoms tend not to be used by those in ongoing relationships.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bangkok-thailand-8-august-2018-various-1156815850?src=MTLGQYZvxdjVj35sPU75VQ-1-0">BORIMAT PRAOKAEW / Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Meanwhile the idea of vasectomy (which should obviously only be undertaken if a decision of no future children is made) is popular with women for equality reasons. It allows couples to take turns over contraceptive responsibility over time. But many men do not seem to be that <a href="https://www.telegraph.co.uk/men/thinking-man/having-vasectomy-dont-tell/">keen</a>. </p>
<p>It’s also important to remember that pregnancy carries some risks for women alone. Even if they are supportive partners, men do not face the same biological issues of either continuing or ending a pregnancy. While there are now challenges to the expectations that women should always be the primary carer of children, changes in attitude cannot overcome this biological reality of pregnancy. </p>
<p>So it’s unsurprising that such apps are popular. Avoiding the health difficulties that many women experience with other contraceptive methods is appealing. But women are still waiting for better contraceptive solutions. In the meantime, reducing the stigma and costs of unintended pregnancy and abortion would an extremely useful step in recalibrating the understanding of the difficult balance women make between embodied impacts and the effectiveness of the current options.</p><img src="https://counter.theconversation.com/content/101563/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pam Lowe has received research funding from the ESRC and Umbrella Partnership/University Hospitals Birmingham NHS Foundation Trust and Birmingham City Council for research on contraception. She is a member of Abortion Rights. </span></em></p>It’s unsurprising that such apps are popular. Contraceptives come with a slew of hazards.Pam Lowe, Senior Lecturer in Sociology, Aston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/956942018-07-09T10:28:27Z2018-07-09T10:28:27ZHow the Catholic Church came to oppose birth control<figure><img src="https://images.theconversation.com/files/226532/original/file-20180706-122265-1v4apf9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pope Paul VI banned contraception for Catholics in the 1968 encyclical, "Humanae Vitae."</span> <span class="attribution"><span class="source">AP Photo/Jim Pringle</span></span></figcaption></figure><p>This month marks the 50th anniversary of the landmark “Humanae Vitae,” Pope Paul VI’s strict prohibition against artificial contraception, issued in the aftermath of the development of the birth control pill. At the time, the decision <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">shocked</a> many Catholic priests and laypeople. Conservative Catholics, however, <a href="https://books.google.com/books/about/Catholic_Intellectuals_and_Conservative.html?id=LK51AAAAMAAJ">praised the pope</a> for what they saw as a confirmation of traditional teachings.</p>
<p>As a <a href="https://scholar.google.com/citations?hl=en&user=8S1ydcsAAAAJ&view_op=list_works&gmla=AJsN-F6AaDdh2HOAlzKGJw3Xk7ZwuHYTAvpym2jdDa8KTvuGKSxei-9Oix4I84Ka55hX765CxCjr35WrEqZX0DxcLADUp0HY8Q">scholar</a> specializing in both the history of the Catholic Church and gender studies, I can attest that for almost 2,000 years, the Catholic Church’s stance on contraception has been one of constant change and development. </p>
<p>And although Catholic moral theology has consistently condemned contraception, <a href="https://books.google.com/books/about/Contraception.html?id=S-fBxgQoYQ0C">it has not always been the church battleground</a> that it is today. </p>
<h2>Early church practice</h2>
<p>The first Christians <a href="https://books.google.com/books/about/Contraception.html?id=S-fBxgQoYQ0C">knew about contraception and likely practiced it</a>. Egyptian, Hebrew, Greek and Roman texts, for example, discuss well-known contraceptive practices, ranging from the withdrawal method to the use of crocodile dung, dates and honey to block or kill semen. </p>
<p>Indeed, while Judeo-Christian scripture encourages humans to <a href="https://www.biblegateway.com/passage/?search=Genesis+1%3A28&version=KJV">“be fruitful and multiply,”</a> nothing in Scripture <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">explicitly prohibits contraception</a>. </p>
<p>When the first Christian theologians condemned contraception, they did so not on the basis of religion but <a href="https://books.google.com/books?id=JbzwS6MzK1gC&pg=PA55&lpg=PA55&dq=Christine+E.+Gudorf+%22Contraception+and+Abortion+in+Roman+Catholicism%22&source=bl&ots=5WJffub6wK&sig=rCNxnaAIZFq7tmfZ787O5KIePOE&hl=en&sa=X&ved=0ahUKEwia_vX5savb%20AhXtHDQIHZuqBqwQ6AEILDAB#v=onepage&q=Christine%20E.%20Gudorf%20%22Contraception%20and%20Abortion%20in%20Roman%20Catholicism%22&f=false">in a give-and-take with cultural practices and social pressures</a>. Early opposition to contraception was often <a href="https://books.google.com/books/about/Contraception.html?id=S-fBxgQoYQ0C">a reaction to the threat of heretic groups,</a> such as the Gnostics and Manichees. And before the 20th century, <a href="https://books.google.com/books?id=JbzwS6MzK1gC&pg=PA55&lpg=PA55&dq=Christine+E.+Gudorf+%22Contraception+and+Abortion+in+Roman+Catholicism%22&source=bl&ots=5WJffub6wK&sig=rCNxnaAIZFq7tmfZ787O5KIePOE&hl=en&sa=X&ved=0ahUKEwia_vX5savb%20AhXtHDQIHZuqBqwQ6AEILDAB#v=onepage&q=Christine%20E.%20Gudorf%20%22Contraception%20and%20Abortion%20in%20Roman%20Catholicism%22&f=false">theologians assumed</a> that those who practiced contraception were “fornicators” and “prostitutes.” </p>
<p>The <a href="http://www.newadvent.org/fathers/1309.htm">purpose of marriage</a>, they believed, was producing offspring. While sex within marriage was not itself considered a sin, <a href="http://www.newadvent.org/fathers/15071.htm">pleasure in sex was</a>. The fourth-century Christian theologian Augustine characterized the sexual act between spouses as <a href="http://www.newadvent.org/fathers/360211064.htm">immoral self-indulgence</a> if the couple tried to prevent conception. </p>
<h2>Not a church priority</h2>
<p>The church, however, had little to say about contraception for many centuries. For example, after the decline of the Roman Empire, <a href="https://books.google.com/books/about/A_History_of_Contraception.html?id=9-R4QgAACAAJ">the church did little to explicitly</a> <a href="https://books.google.com/books/about/The_Theology_of_Marriage.html?id=sASAQgAACAAJ">prohibit contraception</a>, teach against it, or stop it, though people undoubtedly practiced it. </p>
<p>Most penitence manuals from the Middle Ages, which directed priests what types of sins to ask parishioners about, <a href="https://books.google.com/books?id=JbzwS6MzK1gC&pg=PA55&lpg=PA55&dq=Christine+E.+Gudorf+%22Contraception+and+Abortion+in+Roman+Catholicism%22&source=bl&ots=5WJffub6wK&sig=rCNxnaAIZFq7tmfZ787O5KIePOE&hl=en&sa=X&ved=0ahUKEwia_vX5savb%20AhXtHDQIHZuqBqwQ6AEILDAB#v=onepage&q=Christine%20E.%20Gudorf%20%22Contraception%20and%20Abortion%20in%20Roman%20Catholicism%22&f=false">did not even mention contraception</a>.</p>
<p>It was only in 1588 that Pope Sixtus V took the strongest conservative stance against contraception in Catholic history. With his papal bull “Effraenatam,” he ordered all church and civil penalties for homicide to be brought against those who practiced contraception. </p>
<p>However, both church and civil authorities refused to enforce his orders, and laypeople virtually ignored them. In fact, three years after Sixtus’s death, the <a href="https://books.google.com/books/about/Contraception.html?id=S-fBxgQoYQ0C">next pope repealed</a> most of the sanctions and told Christians to treat “Effraenatam” “as if it had never been issued.” </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/como-vino-la-iglesia-catolica-a-oponerse-al-control-de-natalidad-99634">Cómo vino la Iglesia Católica a oponerse al control de natalidad</a>
</strong>
</em>
</p>
<hr>
<p>By the mid-17th century, some church leaders <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">even admitted couples might have legitimate reasons to limit family size</a> to better provide for the children they already had.</p>
<h2>Birth control becomes more visible</h2>
<p>By the 19th century, scientific knowledge about the human reproductive system advanced, and contraceptive technologies improved. New discussions were needed. </p>
<p>Victorian-era sensibilities, however, <a href="https://books.google.com/books/about/Catholics_and_Contraception.html?id=31-_B3EaBskC">deterred most Catholic clergy</a> from preaching on issues of sex and contraception. </p>
<p>When an 1886 penitential manual instructed confessors to ask parishioners explicitly whether they practiced contraception and to refuse absolution for sins unless they stopped, <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">“the order was virtually ignored.”</a> </p>
<p>By the 20th century, Christians in some of the most heavily Catholic countries in the world, such as France and Brazil, were <a href="https://books.google.com/books?id=JbzwS6MzK1gC&pg=PA55&lpg=PA55&dq=Christine+E.+Gudorf+%22Contraception+and+Abortion+in+Roman+Catholicism%22&source=bl&ots=5WJffub6wK&sig=rCNxnaAIZFq7tmfZ787O5KIePOE&hl=en&sa=X&ved=0ahUKEwia_vX5savb%20AhXtHDQIHZuqBqwQ6AEILDAB#v=onepage&q=Christine%20E.%20Gudorf%20%22Contraception%20and%20Abortion%20in%20Roman%20Catholicism%22&f=false">among the most prodigious users</a> of artificial contraception, leading to dramatic decline in family size.</p>
<p>As a consequence of this increasing availability and use of contraceptives by Catholics, church teaching on birth control – which had always been there – began to <a href="https://books.google.com/books/about/Catholics_and_Contraception.html?id=31-_B3EaBskC">become a visible priority</a>. The papacy decided to bring the dialogue about contraception <a href="https://books.google.com/books/about/Devices_and_Desires.html?id=Im8RdEyDX8cC">out of scholarly theological discussions</a> between clergy into ordinary exchanges between Catholic couples and their priests.</p>
<p>Regarding his frank 1930 pronouncement on birth control, “Casti Connubii,” Pope Pius XI declared that contraception was inherently evil and any spouse practicing any act of contraception <a href="https://books.google.com/books?id=S-fBxgQoYQ0C&printsec=frontcover&dq=John+T.+Noonan+contraception&hl=en&sa=X&ved=0ahUKEwj55YrnnbPbAhXjIjQIHbfPAqcQ6AEIJzAA#v=onepage&q=John%20T.%20Noonan%20contraception&f=false;%20https://w2.vatican.va/content/pius-xi/en/encyclicals/documents/hf_p-xi_enc_19301231_casti-connubii.html">“violates the law of God and nature” and was “stained by a great and mortal flaw.”</a> </p>
<p>Condoms, diaphragms, the rhythm method and even the withdrawal method were forbidden. Only abstinence was permissible to prevent conception. Priests were to teach this so clearly and so often that no Catholic could claim ignorance of the Church’s prohibition of contraception. Many theologians presumed this to be an <a href="https://books.google.com/books/about/Catholics_and_Contraception.html?id=31-_B3EaBskC">“infallible statement”</a> and taught it thus to Catholic laypersons for decades. <a href="https://books.google.com/books/about/Catholics_and_Contraception.html?id=31-_B3EaBskC">Other theologians saw it</a> as binding but “subject to future reconsideration.”</p>
<p>In 1951, the church modified its stance again. Without overturning “Casti Connubii’s” prohibition of artificial birth control, Pius XI’s successor, Pius XII, deviated from its intent. He approved the rhythm method for couples who had <a href="https://books.google.com/books/about/Contraception.html?id=S-fBxgQoYQ0C">“morally valid reasons for avoiding procreation,” </a> defining such situations quite broadly.</p>
<h2>The pill and the church</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226537/original/file-20180706-122268-lwwtjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Museum of Sex, in New York, marks the 50th anniversary of the world’s first oral contraceptive in 2010.</span>
<span class="attribution"><span class="source">AP Photo/Bebeto Matthews</span></span>
</figcaption>
</figure>
<p>By the early 1950s, however, options for artificial contraception were growing, including the pill. <a href="https://books.google.com/books?id=0PgkAAAAYAAJ&q=Bromley+Catholics+on+Birth+Control&dq=Bromley+Catholics+on+Birth+Control&hl=en&sa=X&ved=0ahUKEwjumsaDurXbAhXdFjQIHRF0DeEQ6AEIJzAA">Devout Catholics wanted explicit permission to use them</a>. </p>
<p>Church leaders confronted the issue head-on, expressing a variety of viewpoints.</p>
<p>In light of these new contraceptive technologies and developing scientific knowledge about when and how conception occurs, some leaders believed the church could not know God’s will on this issue and should stop pretending that it did, as Dutch Bishop William Bekkers <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">said outright on national television</a> in 1963.</p>
<p>Even Paul VI <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">admitted his confusion</a>. In an interview with an Italian journalist in 1965, he stated, </p>
<blockquote>
<p>“The world asks what we think and we find ourselves trying to give an answer. But what answer? We can’t keep silent. And yet to speak is a real problem. But what? The Church has never in her history confronted such a problem.” </p>
</blockquote>
<p>There were others, however, such as <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">Cardinal Alfredo Ottaviani</a>, leader of the Congregation for the Doctrine of the Faith – the body that promotes and defends Catholic doctrine – who disagreed. Among those adamantly convinced of the truth of the prohibitions was the <a href="https://books.google.com/books/about/John_Cuthbert_Ford_SJ.html?id=F8luZnjkVdAC">Jesuit John Ford</a>, perhaps the most influential U.S. Catholic moralist of the last century. Although no Scripture mentioned contraception, Ford believed the church’s teachings were grounded in divine revelation and therefore not to be questioned.</p>
<p>The question was left for consideration by the Pontifical Commission on Birth Control, held between 1963 to 1966. This commission by an overwhelming majority – a reported 80 percent – recommended the church <a href="https://books.google.com/books/about/Catholics_and_Contraception.html?id=31-_B3EaBskC">expand its teaching</a> <a href="https://books.google.com/books/about/Catholic_Intellectuals_and_Conservative.html?id=LK51AAAAMAAJ">to accept artificial contraception</a>. </p>
<p>That was not at all unusual. The Catholic Church had changed its stance on many controversial issues over the centuries, such as slavery, usury and Galileo’s theory that the Earth revolves around the sun. <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">Minority opinion</a>, however, feared that to suggest the church had been wrong these last decades would be to admit the church had been lacking in direction by the Holy Spirit. </p>
<h2>‘Humanae Vitae’ ignored</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/226535/original/file-20180706-122271-16d09ed.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A protest in Charleston, S.C., in 2012, against a federal mandate requiring employers to provide health insurance that includes birth control for workers.</span>
<span class="attribution"><span class="source">AP Photo/Bruce Smith</span></span>
</figcaption>
</figure>
<p>Paul VI eventually sided with this minority view and issued “Humanae Vitae,” <a href="http://w2.vatican.va/content/paul-vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html">prohibiting all forms of artificial birth control</a>. His decision, many argue, was not about contraception per se but the preservation of church authority. An <a href="https://books.google.com/books/about/Catholic_Intellectuals_and_Conservative.html?id=LK51AAAAMAAJ">outcry ensued from both priests and laypeople</a>. One lay member of the commission <a href="https://books.google.com/books/about/Turning_Point.html?id=0a2RAAAAIAAJ">commented</a>, </p>
<blockquote>
<p>“It was as if they had found some old unpublished encyclical from the 1920s in a drawer somewhere in the Vatican, dusted it off, and handed it out.” </p>
</blockquote>
<p>Much has changed in the Catholic Church since 1968. Today, priests make it a pastoral priority to encourage sexual pleasure between spouses. While prohibitions on birth control continue, many pastors <a href="https://books.google.com/books/about/The_Vatican_Diaries.html?id=i_aMPEpHpBkC">discuss the reasons</a> a couple might want to use artificial contraception, from protecting one partner against a sexually transmitted disease to limiting family size for the good of the family or the planet. </p>
<p>Despite the changes in the church’s attitudes about sex, the prohibitions of “Humanae Vitae” remain. <a href="http://www.pewforum.org/2016/09/28/4-very-few-americans-see-contraception-as-morally-wrong/">Millions of Catholics</a> around the world, however, <a href="https://books.google.com/books?id=5lf4xeSt5-AC&pg=PA171&lpg=PA171&dq=Ruth+Macklin+Cultural+Difference+and+Long+Acting&source=bl&ots=_OUwvw8IKP&sig=KyE41_vBGQXQ9rxGaQANdbSbayY&hl=en&sa=X&ved=0ahUKEwjDmImKq6vbAhV0JDQIHVr9AusQ6AEILzAB#v=onepage&q=Ruth%20&f=false">have simply chosen to ignore them</a>.</p><img src="https://counter.theconversation.com/content/95694/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa McClain does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>July marks 50 years of Pope Paul VI’s encyclical prohibiting contraceptive use. For many years prior to it, the church had not been so explicit on its stance. How did it become such a thorny issue?Lisa McClain, Professor of History and Gender Studies, Boise State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/876142018-05-20T19:49:23Z2018-05-20T19:49:23ZHow to choose the right contraceptive pill for you<figure><img src="https://images.theconversation.com/files/217892/original/file-20180507-166887-wtgu04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When looking for the right pill, women want to weigh up the cost, safety, efficacy and side effects of the pill.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/cvB-vydRJvY">NordWood Themes</a></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/contraceptive-pill-1650">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
<hr>
<p>The <a href="https://www.fpv.org.au/for-you/contraception/daily-contraceptive-pills/contraceptive-pill">combined oral contraceptive pill</a> is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/27373543">most popular contraception</a> in Australia. It’s less invasive than implants or devices that need to be fitted in the arm or uterus, making it an attractive option for many women. </p>
<p>There are more than <a href="https://www.nps.org.au/australian-prescriber/articles/choosing-a-combined-oral-contraceptive-pill#t1">30 types</a> of oral contraceptive pills. Different types and brands of contraceptive pill contain different types and doses of synthetic oestrogen and progesterone. </p>
<p>But brand names such as Microgynon, Levlen, Yaz, Brenda and Norimin give little indication of the ingredients, dose or who should use them. </p>
<p>When looking for the right pill, women want to weigh up the cost, safety, efficacy and side effects of the pill. Some women might also be seeking non-contraceptive benefits, such as treatment for acne, pre-menstrual syndrome, heavy or painful periods, endometriosis, or polycystic ovarian syndrome. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-the-options-for-birth-control-18613">Explainer: what are the options for birth control?</a>
</strong>
</em>
</p>
<hr>
<h2>Cost</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=906&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=906&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=906&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1139&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1139&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217897/original/file-20180507-166910-c63ufu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1139&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A year of the pill costs anywhere between A$20 and A$360.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1014012175?src=9Kcm5et53VQ7XKjNKYT-cg-1-24&size=medium_jpg">Areeya_ann/Shutterstock</a></span>
</figcaption>
</figure>
<p><a href="https://www.nps.org.au/australian-prescriber/articles/choosing-a-combined-oral-contraceptive-pill#guiding-pill-prescription">Current guidelines recommend</a> GPs prescribe pills that are subsidised on the <a href="http://www.pbs.gov.au/pbs/home;jsessionid=1tzyuf0uoaqok1i36kl12bp9ad">Pharmaceutical Benefits Scheme</a> (PBS) for women to trial first. </p>
<p>And at less than A$120 a year (A$20 a year for concession card holders), they are the cheapest.</p>
<p>The newer and more expensive pills claim to be superior in reducing <a href="https://www.ncbi.nlm.nih.gov/pubmed/22786490">acne</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/22336820">PMS</a> or <a href="https://www.ncbi.nlm.nih.gov/pubmed/19835717">menstrual bleeding</a>, which is why they end up being prescribed. But all contraceptive pills have these advantages, and the evidence for supporting one over the other is <a href="https://www.ncbi.nlm.nih.gov/pubmed/22696343/">limited or conflicting</a>.</p>
<p>You’ll <a href="http://www.abc.net.au/news/health/2016-09-23/raw-deal-on-the-pill-new-varieties-not-available-on-low-incomes/7868246">pay up to A$360 per year</a> for non-PBS prescriptions. </p>
<h2>Safety</h2>
<p>Healthy women often take the pill for many years, so its safety profile needs to be excellent. <a href="https://wiki.cancer.org.au/policy/Position_statement_-_Oral_contraceptives#_ga=2.66864684.366100634.1525588428-861852034.1525588428">The risk of breast cancer</a> is slightly increased while on the pill, resulting in an extra 1.5 women per 10,000 women getting breast cancer. But the pill actually protects against endometrial and ovarian cancer. </p>
<p>Taking the pill <a href="https://www.ncbi.nlm.nih.gov/pubmed/23825156/">doubles the risk of venous thromboembolism</a> (or VTE, where clots develop in the brain, legs or lungs), but it’s still less than the risk of developing VTE in late pregnancy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">Don't panic about the pill – it's safer than driving to work</a>
</strong>
</em>
</p>
<hr>
<p>The higher the oestrogen dose, the higher the risk of VTE, which is why pills with 50 micrograms of oestrogen (<a href="https://www.nps.org.au/medical-info/medicine-finder/microgynon-50-ed-tablets">Microgynon 50</a> and <a href="https://www.nps.org.au/medical-info/medicine-finder/norinyl-1-28-day-tablets">Norinyl-1</a>) are very rarely prescribed.</p>
<p>Pills with newer generation progesterones potentially double the risk of <a href="http://www.bmj.com/content/350/bmj.h2135">venous thromboembolism</a>. Yaz Flex – commonly prescribed for its convenient dosing dispenser (<a href="https://www.nps.org.au/medical-info/medicine-finder/yaz-flex-tablets#how-to-take-yaz-flex">Clyk</a>) and its reportedly low risk of weight gain and mood swings – contains one of these newer progesterones. It’s therefore <a href="https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women's%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Combined-hormonal-contraceptives-(C-Gyn-28)-Review-March-2016.pdf?ext=.pdf">not recommended as a “first use pill”</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=165&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=165&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=165&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=207&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=207&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217893/original/file-20180507-166874-35t1l1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=207&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Clyk dispenser releases the daily pill via machine rather than the traditional blister pack.</span>
<span class="attribution"><a class="source" href="http://yaz.xzw.me/">Yaz screenshot</a></span>
</figcaption>
</figure>
<p>The oestrogen dose in the pill is also responsible for the <a href="https://www.ncbi.nlm.nih.gov/pubmed/9617537">very slightly increased</a> risk of strokes and heart attacks. </p>
<p>The risks of VTE, strokes and heart attacks are also affected by a woman’s background risk of these conditions. Women <a href="https://www.ncbi.nlm.nih.gov/pubmed/9617537">may not be able to take the pill</a> if they <a href="http://www.nevdgp.org.au/files/educationevents/Medical%20Eligibility%20Criteria%20for%20Contractive%20Use%20-%20WHO%20summary.pdf">have a history of</a> heart disease, breast cancer, liver disease, VTE or migraines with aura; are over 50 or over 35 and smoke; have a BMI over 35; or have a family history of VTE.</p>
<h2>Efficacy</h2>
<p>The pill’s <a href="http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/failure-rates-table">failure rate of 9%</a> is high compared to long-acting reversible (LARC) forms of contraception, such as IUDs and arm implants. This means nine out of 100 women becoming pregnant after a year on the pill, compared with less than one women with an IUD or arm implant. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">Few Australian women use long-acting contraceptives, despite their advantages</a>
</strong>
</em>
</p>
<hr>
<p>If taken perfectly, the pill should work <a href="http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/failure-rates-table">99.7% of the time</a>. But fewer than <a href="https://www.ncbi.nlm.nih.gov/pubmed/28874178">20% of pill takers</a> in one study were able to do that every month. And if you do miss a pill, the <a href="https://www.medscape.com/viewarticle/745447">complicated rules</a> surrounding missed pills are <a href="https://www.ncbi.nlm.nih.gov/pubmed/23040136">difficult to remember and understand</a>. </p>
<p>Decreasing the risk of unwanted pregnancy is best addressed by <a href="https://www.tandfonline.com/doi/full/10.3109/13625187.2010.529969">extending</a> whatever regime you pick. This means that rather than taking 21 active pills and seven inactive (sugar) pills to mimic a menstrual bleed, you take <a href="https://www.nps.org.au/australian-prescriber/articles/choosing-a-combined-oral-contraceptive-pill#effective-regimens">84 active pills</a>, followed by seven inactive pills and have a “withdrawal” bleed once every three months. </p>
<p>By running the pill packs together, you reduce the risk of ovulating if a pill is accidentally missed. </p>
<h2>Side effects</h2>
<p>The unwanted side effects of the pill include breakthrough bleeding, <a href="https://theconversation.com/theres-no-rushing-womens-syndrome-but-hormones-affect-mental-health-28136">mood changes</a>, weight gain, sore breasts and acne.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217895/original/file-20180507-166906-1yeq4yz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pill usually reduces acne, but some women may experience it as a side effect.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1083859292?src=kCBgB50qgLnSMjW8uU5yKQ-1-15&size=medium_jpg">Yurakrasil/Shutterstock</a></span>
</figcaption>
</figure>
<p>After a three month trial, if you experience any of these unwanted effects, but want to stick with the pill as a form of contraception, it might be helpful to change types or doses of hormones. For example:</p>
<ul>
<li><p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938905/">headaches</a> can be addressed by reducing the dose of oestrogen or changing to the newer oestradiol in <a href="https://www.nps.org.au/medical-info/medicine-finder/qlaira-tablets">Qlaira</a></p></li>
<li><p>nausea can be alleviated by taking the pill at night or reducing the oestrogen dose</p></li>
<li><p>breast tenderness and bloating can be treated by reducing the oestrogen or changing the progesterone to <a href="https://www.nps.org.au/australian-prescriber/articles/drospirenone-ethinyloestradiol">drospirenone</a>, which acts as a mild diuretic.</p></li>
<li><p>breakthrough bleeding can be addressed by remembering to take the pill at the same time each day. If that isn’t the problem, changing the progesterone type may work, particularly to norethisterone, which is in <a href="https://www.nps.org.au/medical-info/medicine-finder/brevinor-28-day-tablets">Brevinor</a> and <a href="https://www.nps.org.au/medical-info/medicine-finder/norimin-28-day-tablets">Norimin</a>.</p></li>
</ul>
<h2>Non-contraceptive benefits</h2>
<p><strong>Heavy or painful menstrual bleeding</strong></p>
<p>All hormonal contraception will change women’s menstrual bleeding patterns, generally to make it lighter or non-existent. And because you can skip the sugar pills, you can pick when and how often you bleed. </p>
<p>Most women experience <a href="https://www.racgp.org.au/afp/2017/october/the-management-of-irregular-bleeding-in-women-using-contraception/">irregular bleeding</a> when starting on the pill, but this generally decreases over the first three months. </p>
<p>Pills containing higher doses of oestrogen are better at reducing break through or irregular bleeding. <a href="https://www.nps.org.au/medical-info/medicine-finder/loette-tablets">Loette</a> or <a href="https://www.nps.org.au/medical-info/medicine-finder/microgynon-20-ed-tablets">Microgynon 20</a>, which have the lowest dose of oestrogen on the market – 20mcg of ethinyl oestradiol – won’t be as good if heavy and irregular bleeding is your problem. </p>
<p>Pills with the progesterone norethisterone, which is found in <a href="https://www.nps.org.au/medical-info/medicine-finder/brevinor-28-day-tablets">Brevinor</a> and <a href="https://www.nps.org.au/medical-info/medicine-finder/norimin-28-day-tablets">Norimin</a>, are generally considered to reduce bleeding more than the progesterone called levonorgestral (which is found in pills such as <a href="https://www.nps.org.au/medical-info/medicine-finder/monofeme-tablets">Monofeme</a>, <a href="https://www.nps.org.au/medical-info/medicine-finder/levlen-ed-tablets">Levlen</a> and <a href="https://www.nps.org.au/medical-info/medicine-finder/microgynon-30-ed-tablets">Microgynon</a>).</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217894/original/file-20180507-166893-ueyyen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pill usually reduces bleeding.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/718679488?size=medium_jpg">Shinja jang/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Endometriosis</strong></p>
<p>The pill can be an effective way to treat endometriosis by suppressing the menstrual cycle. A continuous regime, skipping periods, is used to slow endometrial growth. </p>
<p><strong>Acne</strong></p>
<p>Reducing the acne-causing androgen hormones can help treat acne, alongside topical or antibiotic treatments. <a href="http://ep.bmj.com/content/90/4/ep98">All pills will do this</a>. </p>
<p>The progesterone <a href="https://www.nps.org.au/australian-prescriber/articles/cyproterone-acetate-ethinyloestradiol">cyproterone acetate</a> is used by itself for acne and is found in pills such as <a href="https://www.nps.org.au/medical-info/medicine-finder/brenda-35-ed-tablets">Brenda-35ED</a> and <a href="https://www.nps.org.au/medical-info/medicine-finder/diane-35-ed-tablets">Diane-35ED</a>, which are marketed for use in people with severe acne. However, there’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/22696343/">little evidence</a> they’re more effective than other pills at treating acne.</p>
<p><strong>Premenstrual syndrome</strong></p>
<p>Premenstrual syndrome (PMS) is a common condition that causes cramps, irritability, mood swings and tender breasts before a period. It can be debilitating in its more severe form of premenstrual dysphoric disorder (PMDD). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-affect-our-mood-42422">Chemical messengers: how hormones affect our mood</a>
</strong>
</em>
</p>
<hr>
<p>Suppressing the hormonal fluctuations during the menstrual cycle using the contraceptive pill can help alleviate symptoms.</p>
<p>If pills listed on the PBS such as <a href="https://www.nps.org.au/medical-info/medicine-finder/levlen-ed-tablets">Levlen</a> are ineffective, your GP might recommend the combination of low-dose oestrogen and a type of progesterone called <a href="https://www.nps.org.au/australian-prescriber/articles/drospirenone-ethinyloestradiol">drospirenone</a>, found in <a href="https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014036/">Yaz</a>. </p>
<p><strong>Polycystic ovarian syndrome</strong></p>
<p>Women with polycystic ovarian syndrome (PCOS) can suffer from acne, irregular periods and excess hair. The pill is <a href="https://jeanhailes.org.au/health-a-z/pcos/management-treatment">one way to treating these symptoms</a>, along with lifestyle changes. </p>
<p><strong>Breastfeeding</strong></p>
<p>The mini pill is a <a href="https://www.fpv.org.au/for-you/contraception/daily-contraceptive-pills/the-mini-pill">progesterone only pill</a>, used mainly by breastfeeding mothers and those who can’t have oestrogen. </p>
<p>Users have a three-hour window to take their daily dose, otherwise it becomes ineffective. This dosing makes it difficult for most people to take effectively. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=469&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=469&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=469&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=589&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=589&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217896/original/file-20180507-166900-1mdl5ch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=589&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Breastfeeding women on the pill need to take it at the same time every day.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-beautiful-mother-breastfeeding-her-newborn-1005876886">Tomsickova Tatyana/Shutterstock</a></span>
</figcaption>
</figure>
<p>Given the <a href="https://www.fpv.org.au/for-you/contraception/long-acting-reversible-contraception-larc/contraceptive-implant-implanonand">contraceptive implant hormonal IUD</a> can be used in breastfeeding women and those who can’t have oestrogen, and more reliably prevents pregnancy, the mini pill has few benefits.</p>
<h2>Find what is best for you</h2>
<p>The combined oral contraceptive pill has some great non-contraceptive benefits but some <a href="https://www.ncbi.nlm.nih.gov/pubmed/9617537">serious side effects</a>. Given the number of pills on the market to choose from, unwanted effects don’t need to be tolerated. You don’t need to commit the detail above to memory; your GP will guide you through the process of finding the right pill for you.</p>
<p>If the failure rate of the pill is an issue, or if changing your pill hasn’t alleviated your side effects, talk to your GP about reversible contraceptive options, including non-hormonal IUDs, which further reduce the risk of pregnancy and last five to ten years.</p><img src="https://counter.theconversation.com/content/87614/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anita Phillips does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are more than 30 different types of contraceptive pills. But brand names such as Microgynon, Levlen, Yaz and Brenda give little indication of the ingredients, dose or who should use them.Anita Phillips, Deputy Director of Clinical Studies, School of Medicine, Faculty of Health, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/924242018-05-15T03:37:26Z2018-05-15T03:37:26ZInformed consent: women need to know about the link between the pill and depression<figure><img src="https://images.theconversation.com/files/217683/original/file-20180504-153888-i3w8ij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some women are very sensitive to small shifts in oestrogen and progesterone; others aren't.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
<hr>
<p>The introduction of the contraceptive pill in the 1960s was a major milestone for female empowerment. It allowed women to separate sex from procreation, and to increase their participation in work outside the home.</p>
<p>Now, <a href="https://www.k4health.org/sites/default/files/l13.pdf">more than 100 million women worldwide</a> use the oral contraceptive pill to prevent pregnancy or control their menstruation.</p>
<p>But the pill and other hormone contraceptives are not without side effects. We usually focus on the physical health effects of the pill, yet the <a href="https://www.ncbi.nlm.nih.gov/pubmed/15236788">most common reason</a> women stop or change the pill is mental health side effects. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-affect-our-mood-42422">Chemical messengers: how hormones affect our mood</a>
</strong>
</em>
</p>
<hr>
<p>Depression is one of the most prevalent and debilitating mental disorders in Australia, and <a href="https://www.researchgate.net/publication/50866070_McLean_CP_Asnaani_A_Litz_BT_Hofmann_SG_Gender_differences_in_anxiety_disorders_prevalence_course_of_illness_comorbidity_and_burden_of_illness_J_Psychiatr_Res_45_1027-1035">affects twice as many women</a> as men. It is estimated that one in four women will experience depression in her lifetime. </p>
<p><a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/2f762f95845417aeca25706c00834efa/e50a5b60e048fc07ca2570ec001909fb!OpenDocument">One in four Australian women</a> between the ages of 18 and 49 use the pill, at any one time. But few are aware of the link between the pill and depression.</p>
<h2>Types of contraceptive pill</h2>
<p>There are many oral contraceptives available in Australia, with different types and doses of the hormones oestrogen and progesterone. </p>
<p>The most commonly prescribed is a combination pill, which contains an oestrogen to prevent ovulation, and a progesterone to reduce the chance of a fertilised egg implanting into the wall of the uterus. </p>
<p>Most combined oral contraceptives have a similar dose and type of oestrogen, but the progesterone types and doses vary widely. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217709/original/file-20180504-153869-ng6dch.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Different types of contraceptive pills contain varying doses of oestrogen and progesterone.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>There are also several <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1728-4465.2005.00038.x">progesterone-only contraceptives</a> that do not contain oestrogen. These are known as the “mini-pill”, or injected contraceptive (“depot provera”), or the skin implanted “straw” (Implanon or Norplant).</p>
<h2>Hormones and mental health</h2>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/25222701">recent review</a> has shown that sex hormones have significant impact on brain areas related to emotional and cognitive functioning. Progesterones <a href="https://www.ncbi.nlm.nih.gov/pubmed/2725334">have been shown to induce depression</a>, particularly in <a href="https://www.ncbi.nlm.nih.gov/pubmed/1846872">vulnerable women</a>. </p>
<p>Synthetic progesterone (more than natural progesterone) has <a href="https://www.ncbi.nlm.nih.gov/pubmed/9044441">significant effects</a> on the brain chemicals serotonin and monoamine oxidase, resulting in depression, irritability and anxiety.</p>
<p>There is a great deal of variation in the effects of hormone shifts on mood and behaviour. Some women are very sensitive to small shifts in oestrogen and progesterone; others aren’t.</p>
<h2>What does the research say?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/17688380">Our research</a> has involved measuring the clinical impact of various types of oral contraceptive pill on mood and anxiety. Overall, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">we found</a> woman taking the oral contraceptive pill were more likely to be depressed than non-pill users. </p>
<p>Women taking the pills with low amounts of oestrogen had more depression than those taking higher oestrogen dose pills. </p>
<p>Certain types of progesterone were more “depressive” than other progesterones, but the progesterone-only contraceptives were the most depressive of all the contraceptives.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/biology-is-partly-to-blame-for-high-rates-of-mental-illness-in-women-the-rest-is-social-75700">Biology is partly to blame for high rates of mental illness in women – the rest is social</a>
</strong>
</em>
</p>
<hr>
<p>A <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2552796">2016 Danish study</a> of more than one million women supports our clinical findings. The researchers found that, compared to non-users, women aged 15-34 who took the combined oral contraceptive pill were 1.23 times more likely to be diagnosed with depression and prescribed antidepressant medication.</p>
<p>Adolescents aged 15-19 who used combined oral contraceptives had an even higher rate of depression than older women. They were 1.8 times more likely to be diagnosed with depression than the non-pill using peers, and this increased to 2.2 times among adolescents using progesterone-only contraceptives. </p>
<p>The study concluded that depression is a significant potential side effect of hormonal contraceptive use, especially in adolescents.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217706/original/file-20180504-138586-1cbqqyu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Adolescents taking the pill appear to be at higher risk of depression than women in older age groups.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<h2>It’s not all bad news</h2>
<p>Emerging research <a href="https://www.ncbi.nlm.nih.gov/pubmed/24856205">by our group</a> and others suggests the combined contraceptive pill may improve “verbal memory” or memory for words and language. This is thought to be driven by oestrogen, which has been shown to positively influence memory-related brain regions. </p>
<p>Research also suggests that pills containing progesterones that are structurally more like testosterone improve visual-spatial skills (traditionally, a male-dominant skill) and pill types containing other progesterones may worsen visual-spatial skills.</p>
<h2>Finding the right contraception</h2>
<p>There are many types of hormone contraceptives and their use needs to be tailored carefully for the individual, especially among adolescents. Women and their doctors need to be aware that hormone contraceptives can contribute to mental health problems, and women should return to their GP if they experience mental health side effects. </p>
<p>The development of new hormone contraceptives that don’t impact adversely on brain chemistry is well overdue. Women must have the right to control their fertility without compromising their enjoyment of life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/chemical-messengers-how-hormones-change-through-menopause-56921">Chemical messengers: how hormones change through menopause</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/92424/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayashri Kulkarni conducts many clinical trials and has received funding from the National Health and Medical Research Council of Australia, is on the Swisse Scientific Advisory Board, has received research grants from pharmaceutical companies – Jansen Cilag and Servier. The work presented in this article on the contraceptive pill was not funded by any external funding agencies and is completely independent research. No makers of any contraceptive pill or device has been involved in any way with this research.
</span></em></p><p class="fine-print"><em><span>Caroline Gurvich has received funding from the National Health and Medical Research Council of Australia. </span></em></p>We usually focus on the physical health effects of the pill, yet the most common reason women stop or change the pill is mental health side effects.Jayashri Kulkarni, Professor of Psychiatry, Monash UniversityCaroline Gurvich, Senior Research Fellow and Clinical Neuropsychologist, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/879402018-05-13T20:31:52Z2018-05-13T20:31:52ZNo, women don’t need to ‘take a break’ from the pill every couple of years<figure><img src="https://images.theconversation.com/files/216084/original/file-20180424-94115-scxxxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The pill is the most popular form of contraception for women under 30.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/klOo6lqKWjs">Tyler Nix</a></span></figcaption></figure><p><em>ON THE PILL: In this <a href="https://theconversation.com/au/topics/pill-series-52834">seven-part series</a> we explore the history, myths, side-effects and alternatives of the pill, and why it’s the most popular form of contraception in Australia.</em></p>
<hr>
<p>More than half of 18- to 19-year-old women in a <a href="http://www.sciencedirect.com/science/article/pii/S1049386714000097">recent survey</a> agreed that “women should ‘take a break’ from oral contraceptive pills every couple of years”. </p>
<p>You may be surprised to know there is no biological evidence for “giving your body a break” and, in fact, it could do your health more harm than good.</p>
<h2>Suitability</h2>
<p>There are many different <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">types</a> of contraceptive pills, most commonly containing both oestrogen and progestogen (called combined oral contraceptive pills). </p>
<p>Doctors use detailed <a href="https://www.clinicalguidelines.gov.au/portal/2101/contraception-australian-clinical-practice-handbook-third-edition">medical eligibility criteria</a> to assess whether a method of contraception is suitable for you on the basis of your medical history. The pill is not suitable for some people. Others may start taking it but find that it doesn’t suit them.</p>
<p>But for many women the pill provides a convenient, easily accessible method of contraception. In fact, it’s the most <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">popular</a> form of contraception for women under the age of 30.</p>
<h2>Hormone build-up?</h2>
<p>Studies in the <a href="https://academic.oup.com/humrep/article/28/6/1620/605060">United States</a>
and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26359250">Australia</a> have found that many women worry about overdosing or having a build-up of hormones in their body if they use hormonal contraception. These types of misconceptions about the way the pill works fuel the erroneous idea that it’s good to take a break from the pill. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/mondays-medical-myth-the-pill-increases-your-risk-of-cancer-6931">Monday’s medical myth: the pill increases your risk of cancer</a>
</strong>
</em>
</p>
<hr>
<p>For some people, the pill can be associated with unpleasant <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">side effects</a> such as breast tenderness, bloating, headaches and nausea. </p>
<p>But rather than being an effect of the hormones themselves, these unpleasant side effects are most commonly associated with the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">hormone-free interval</a> which allows a “withdrawal” bleed to occur, mimicking a natural menstrual cycle. </p>
<p>These <a href="http://srh.bmj.com/content/39/4/237.full">side effects may be lessened</a> by new pills or pill regimes with reduced or no hormone-free intervals (and therefore fewer or no withdrawal bleeds).</p>
<p>Once a doctor prescribes the pill for you, it’s generally recommended that you keep taking it for <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/">at least three months</a> to allow any unpleasant side effects to resolve themselves. </p>
<p>Whether or not a particular pill is problematic for a woman does not change with the duration of use. In fact, any initial side effects you had on starting will be experienced again after a break. For these reasons, it’s best to find a pill that suits you and stick with it. </p>
<p>Of course, as you age your contraceptive needs will change, so it’s important to review your contraception periodically. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19913147">Research</a> shows that Australian women reduce their reliance on the oral contraceptive pill over time as they try to conceive, have children, complete their families, and move towards menopause.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216086/original/file-20180424-94160-15832pr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There are many different types of oral contraceptive pill.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1061861099?src=-2eq5oPR8qcUqC3vlg4oAg-3-12&size=medium_jpg">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Serious health risks?</h2>
<p>Like all medicines, there is a small risk of serious health effects associated with the pill. The risk of serious adverse side effects is <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">highest</a> in the first few months of starting the pill, or when restarting after a break. So it may be more risky to start and stop the pill than it is to use the pill over many years.</p>
<p>Despite the very low risk of health complications associated with the pill, people’s fears are exacerbated by “<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">pill scares</a>” – misrepresented studies reported in the media – which are usually not based on an accurate understanding of the risks.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-panic-about-the-pill-its-safer-than-driving-to-work-42325">Don't panic about the pill – it's safer than driving to work</a>
</strong>
</em>
</p>
<hr>
<p>One of the most serious adverse health effects associated with the pill is <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">thrombotic complications</a> such as stroke, myocardial infarction, and venous thromboembolism (VTE) – in other words, blood clots in the brain, heart, legs, arms and groin. This is why the pill may not be suitable for older women, particularly those who smoke. </p>
<p>However, <a href="https://www.ncbi.nlm.nih.gov/pubmed/29462093">the pill is suitable</a> for women in mid-life who aren’t at increased risk of heart disease.</p>
<p>Although potentially very serious, the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">absolute risk</a> of blood clots is <a href="https://www.ncbi.nlm.nih.gov/pubmed/27051991">very low</a>. This risk is marginally higher than for women not taking the pill, but is lower than the risk associated with pregnancy, delivery and the postpartum period.</p>
<p>Some people may be concerned about the risk of cancer associated with long-term use of the pill. There is a slightly increased risk of <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61684-5/fulltext">cervical cancer</a> but a reduced risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/26390802">ovarian and endometrial cancer</a>. The findings about the risk of <a href="https://www.ncbi.nlm.nih.gov/pubmed/8899264">breast cancer</a> are not conclusive.</p>
<p>It’s also important to note there are a number of <a href="http://onlinelibrary.wiley.com/doi/10.1002/psb.1600/full">non-contraceptive benefits</a> of the pill, including better cycle control; improved premenstrual symptoms, acne, pain, heavy menstrual bleeding and iron-deficiency anaemia; and a reduction in ovarian cysts, benign breast disease and possibly pelvic inflammatory disease. </p>
<p>These non-contraceptive side effects often form the basis for <a href="https://www.ncbi.nlm.nih.gov/pubmed/2681143">women’s choice</a> of contraception. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216089/original/file-20180424-94118-lwzcu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The pill can help reduce period pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1069512443?src=mwuaZZwEP1ydKP3OQTE2OQ-1-8&size=medium_jpg">Rawpixel.com/Shutterstock</a></span>
</figcaption>
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<h2>Fertility</h2>
<p>One of the concerns women have about long-term pill use is that they will find it difficult to conceive. <a href="https://www.ncbi.nlm.nih.gov/pubmed/20818837">Research across a number of countries</a> shows women want their fertility to return quickly after they stop using the pill. </p>
<p>Many factors influence the time it takes for a woman to conceive so it’s difficult to determine the role of the oral contraceptive pill. Some <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268187">research</a> documents a temporary delay in conceiving, usually only lasting a few months. </p>
<p>However, a <a href="https://www.ncbi.nlm.nih.gov/pubmed/22018120">review</a> of 17 studies found typical one-year pregnancy rates following discontinuation of the pill ranged between 79% and 96%, which is similar to women who stopped using condoms or weren’t using another form of contraception.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/mondays-medical-myth-the-pill-affects-long-term-fertility-8150">Monday's medical myth: the pill affects long-term fertility</a>
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<h2>What should you do?</h2>
<p>If the pill suits you, <a href="https://www.mayoclinic.org/healthy-lifestyle/birth-control/expert-answers/birth-control-pills/faq-20058110">there’s no need</a> to “give your body a break”. </p>
<p>But it’s important to have regular health checks and also <a href="https://www.ncbi.nlm.nih.gov/pubmed/23210098">review your contraceptive needs</a> periodically. This is particularly relevant at significant times in your reproductive life – on becoming sexually active, being with a new partner, if you’re thinking of having a baby, after having a baby, and when you’ve decided not to have any more children.</p>
<p>It’s always worth finding out about the <a href="https://theconversation.com/explainer-what-are-the-options-for-birth-control-18613">latest contraceptive options</a> so you can be sure you’re using contraception that’s right for you.</p><img src="https://counter.theconversation.com/content/87940/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jayne Lucke is the Director of the Australian Research Centre in Sex, Health and Society at La Trobe University. She receives funding from the Australian Research Council and the National Health and Medical Research Council. She has served as a Director of Family Planning Queensland and been Chief Investigator on an ARC Linkage Grant that involves cash and in-kind support from Family Planning New South Wales and Bayer Australia. The Australian Research Centre in Sex, Health and Society receives funding from diverse sources listed in the annual report available from the website: <a href="http://www.latrobe.edu.au/arcshs">http://www.latrobe.edu.au/arcshs</a>.</span></em></p>There is no biological evidence for “giving your body a break” and in fact, it could do your health more harm than good.Jayne Lucke, Professor & Director of the Australian Research Centre in Sex, Health & Society, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/904102018-01-30T11:32:08Z2018-01-30T11:32:08ZPromising male birth control pill has its origin in an arrow poison<figure><img src="https://images.theconversation.com/files/203914/original/file-20180130-89590-1n68uqn.jpg?ixlib=rb-1.1.0&rect=351%2C0%2C2144%2C1470&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will blue packets replace pink ones soon?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-contraceptive-pill-746870245">Aleksandra Berzhets/Shutterstock.com</a></span></figcaption></figure><p>After decades of research, development of a male birth control may now be one step closer. My colleagues and I are working on a promising lead for a <a href="https://doi.org/10.1021/acs.jmedchem.7b00925">male birth control pill based on ouabain</a> – a plant extract that African warriors and hunters traditionally used as a heart-stopping poison on their arrows.</p>
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<a href="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203915/original/file-20180130-89582-1h4a3d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Hunters want ouabain to be deadly when used on an arrow, but no one wants a fatal contraceptive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/poison-on-arrow-784275280">PLANET EARTH/Shutterstock.com</a></span>
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<h2>State of the search</h2>
<p>While the birth control pill has been available to women in the United States for nearly six decades – and FDA-approved for <a href="http://www.mum.org/enovid-e.htm">contraceptive use since 1960</a> – an oral contraceptive for men has not yet come to market. The pill has provided women with safe, effective and reversible options for birth control, while options for men have been stuck in a rut.</p>
<p>Today, <a href="https://doi.org/10.4103/2230-8210.102991">men have just two choices</a> when it comes to birth control: condoms or a vasectomy. Together, these two methods account for just <a href="https://www.malecontraceptive.org/why-male-contraception-dr-john-amory/">30 percent of contraception used</a>, leaving the remaining 70 percent of contraceptive methods to women. An estimated <a href="https://doi.org/10.21037/tau.2017.07.22">500,000 American men opt for a vasectomy each year</a> – a small number given the need for contraception. Vasectomy is an invasive procedure to do that’s also difficult and invasive to reverse.</p>
<p>When it comes to birth control options for men, the need is clear. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23689167">Unplanned pregnancy rates</a> remain high across the globe. It’s time for more options.</p>
<h2>Hormonal versus nonhormonal</h2>
<p>Researchers are exploring both hormonal and nonhormonal options for male birth control pills. Current <a href="https://doi.org/10.1002/14651858.CD004316.pub2">hormonal agents under study</a> involve the sex steroids progestins and testosterone.</p>
<p>While the male hormonal birth control pill option <a href="https://doi.org/10.1210/jc.2016-2141">is in clinical human trials</a> and likely closer to market, it has <a href="https://doi.org/10.1097/MED.0b013e3282fcc30d">several potential side effects</a>: In addition to potentially causing weight gain and changes in libido, it has the ability to lower the levels of good cholesterol (HDL-C) in men, which could negatively affect the heart health of users. The long-term effects of using hormones for male oral contraception are unknown, and it will likely be decades before this information is available.</p>
<p>Here at the University of Minnesota, my colleagues and I have focused on <a href="https://doi.org/10.1016/j.pep.2016.01.009">nonhormonal contraception methods</a> that <a href="https://doi.org/10.1002/cmdc.201700503">work by targeting</a> <a href="https://doi.org/10.1038/35098027">sperm motility</a> – biology-speak for the sperms’ ability to move or swim effectively. <a href="https://en.wikipedia.org/wiki/Sperm_motility">Good motility</a> is a necessary condition for fertilizing a female egg.</p>
<p>In collaboration with <a href="http://www.kumc.edu/school-of-medicine/molecular-and-integrative-physiology/faculty/faculty/v-gustavo-blanco-md-phd.html">Gustavo Blanco</a> at the University of Kansas, we’ve homed in on ouabain: a toxic substance produced by two types of African plants. Mammals also produce ouabain in their bodies, though at lower nonlethal levels that scientists think can help control blood pressure. In fact, physicians have used ouabain in very small doses to treat patients with heart arrhythmias or suffering from heart attacks.</p>
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<a href="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=285&fit=crop&dpr=1 600w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=285&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=285&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=358&fit=crop&dpr=1 754w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=358&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/203870/original/file-20180129-89577-4p34d8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=358&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A cross-section of a cell membrane shows how pumps made of protein subunits move sodium and potassium ions in and out of the cell.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:0308_Sodium_Potassium_Pump.jpg">OpenStax</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<h2>From toxin to contraceptive</h2>
<p>Researchers know that ouabain disrupts the passage of sodium and potassium ions through cell membranes; it interferes with the proper function of proteins that transport the ions in and out of cells. Some of the ion-transporting protein subunits targeted by ouabain are found in cardiac tissue – its ability to disrupt proper heart function is what makes ouabain a deadly poison. But ouabain also affects another type of transporter subunit called α4, which is found only in sperm cells. This protein is known to be <a href="https://doi.org/10.1073/pnas.1016902108">critical in fertility</a> — at least in male mice.</p>
<p>For 10 years, my colleagues and I have been studying ouabain as a potential breakthrough in our quest for a male birth control pill. However, ouabain by itself isn’t an option as a contraceptive because of the risk of heart damage. So we set out to design ouabain analogs – versions of the molecule that are more likely to bind to the α4 protein in sperm than other subunits in heart tissue.</p>
<p>In the lab, we used the techniques of <a href="https://www.acs.org/content/acs/en/careers/college-to-career/chemistry-careers/medicinal-chemistry.html">medicinal chemistry</a> to create a derivative of ouabain that is good at zeroing in on the α4 transporter in sperm cells in rats. Once bound to those cells, it interferes with the sperms’ ability to swim – essential to its role in fertilizing an egg. Our new compound showed no toxicity in rats.</p>
<p>Because the α4 transporter is found only on mature sperm cells, the contraceptive effect should be reversible – sperm cells produced after stopping the treatment presumably won’t be affected. Ouabain may also offer men a birth control pill option with fewer systemic side effects than hormonal options.</p>
<h2>Next steps on the road to drug discovery</h2>
<p>Our results are promising because our candidate molecule, unlike ouabain, is nontoxic in rats. Our modification is a big step forward in the process of developing a nonhormonal male birth control pill. But there’s a lot left to do before men can buy this contraceptive at the pharmacy.</p>
<p>After our ouabain analog showed <a href="https://doi.org/10.1530/REP-09-0495">promise in rat studies</a> at reducing sperm motility, future studies will focus on the effectiveness of our lead compound as an actual contraceptive in animals. We need to prove that a reduction in sperm movement translates into a drop in egg fertilization.</p>
<p>Then, we’ll begin the standard steps in drug discovery such as toxicology and safety pharmacology studies as we advance toward planning and conducting clinical trials. Our team is already taking the next step to <a href="https://doi.org/10.1095/biolreprod.106.057810">test our compound in animal mating trials</a>. If things continue as planned, we hope to get to human clinical trials within five years.</p>
<p>Reversible, effective male birth control is within sight. World Health Organization numbers suggest that <a href="https://doi.org/10.1093/humupd/dmp048">reducing sperm motility by 50 percent or less</a> is sufficient to temporarily make a man infertile. Our ongoing research brings us one step closer to expanding the options for male birth control, providing the world’s 7.6 billion people with a much-needed option for safe and reversible contraception.</p><img src="https://counter.theconversation.com/content/90410/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This research was funded by the National Institutes of Health Eunice Kennedy Shriver National Institute of Child Health and Human Development.</span></em></p>Medicinal chemists are tweaking a natural molecule that can be a deadly poison – a modified version might work as a nonhormonal male contraceptive.Gunda Georg, Professor of Medicinal Chemistry and Director of the Institute for Therapeutics Discovery and Development, University of MinnesotaJon Hawkinson, Research Professor of Medicinal Chemistry and Associate Program Director of the Institute for Therapeutics Discovery and Development, University of MinnesotaShameem Syeda, Principal Scientist at the Institute for Therapeutics Discovery and Development, University of MinnesotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/890742017-12-13T01:14:50Z2017-12-13T01:14:50ZReporting a few cases of negative side effects from long-acting contraceptives is alarmist and damaging<figure><img src="https://images.theconversation.com/files/198899/original/file-20171213-31725-8bez8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An unbalanced report failed to mention the experience of most women who use long acting reversible contraceptives. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Last night ABC’s 7.30 featured a <a href="http://www.abc.net.au/news/2017-12-12/spotlight-on-mirena-and-implanon-contraceptive-devices/9247960">report on long-acting reversible contraception</a> (LARC) that was unbalanced and alarmist. This could have a long-lasting detrimental impact on women’s reproductive health in Australia.</p>
<p>The segment focused on the contraceptive implant (Implanon NXT) and the intrauterine system (Mirena) and presented two cases of women who experienced adverse side effects from use of these methods. </p>
<p>The report completely failed to present the experience of the majority of women who are happy with these devices and reap many benefits. These include reduced period bleeding and pain, as well as reliable protection from unintended pregnancy.</p>
<p>In studies where women are followed up a year after commencing one of these methods, over 80% of women continue to use them. This reflects <a href="https://www.ncbi.nlm.nih.gov/pubmed/21508749">high levels</a> of <a href="https://www.ncbi.nlm.nih.gov/pubmed/20541171">satisfaction</a>.</p>
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<strong>
Read more:
<a href="https://theconversation.com/iuds-safe-effective-but-myths-live-on-10852">IUDs safe, effective but myths live on</a>
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<p>The figures of adverse events quoted by the ABC demonstrate how uncommon any major complications are - affecting less than one in a thousand women. Large <a href="https://www.ncbi.nlm.nih.gov/pubmed/20541171">patient trials</a> have <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1110855">consistently found</a> these devices to be extremely safe and highly effective at preventing pregnancy.</p>
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<p>All consultations about contraception involve discussing the risks and benefits of different methods. Women should be able to make a fully informed decision that best suits their needs.</p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2910826/">large study in the US</a> (the CHOICE study) involving more than 7,000 women showed, when provided with evidence-based information, more than two-thirds of women chose a LARC method with high levels of <a href="https://www.ncbi.nlm.nih.gov/pubmed/21508749">continuation</a> and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1110855">satisfaction</a>. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pubmed/18372257">body of evidence</a> in favour of the use of long-acting contraceptive methods is <a href="https://www.ncbi.nlm.nih.gov/pubmed/21656970">so strong</a> the World Health Organisation supports strategies to <a href="https://www.nap.edu/read/12648/chapter/1">increase their uptake</a>. Increasing access to LARC methods is a health priority of governments in the US and UK.</p>
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Read more:
<a href="https://theconversation.com/few-australian-women-use-long-acting-contraceptives-despite-their-advantages-44896">Few Australian women use long-acting contraceptives, despite their advantages</a>
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<p>The reason for this widespread support for LARC methods comes from reports finding <a href="https://www.ncbi.nlm.nih.gov/pubmed/16772190">half of unintended pregnancies</a> result from use of contraceptive methods that require daily adherence such as pills and condoms. No interventions have been found to improve regularity or consistency of use of these methods, nor to lower unintended pregnancies.</p>
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<p>Because of high fertility and less reliable adherence to contraceptive methods, <a href="https://www.guttmacher.org/journals/psrh/2001/11/differences-teenage-pregnancy-rates-among-five-developed-countries-roles">adolescents and young women</a> may be particularly susceptible to unintended pregnancy. </p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-the-options-for-birth-control-18613">Explainer: what are the options for birth control?</a>
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<p>The <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1110855">CHOICE study in the US</a> reported that among all 14-45 year-old women, 67% chose to use an implant or an intrauterine device. When followed up for three years their risk of unintended pregnancy was 20 times lower compared with women who had chosen to use a contraceptive pill, patch or ring, which require taking or changing regularly.</p>
<p>This reporting by the ABC is irresponsible and detrimental to women’s health. Dedicated health professionals strive to improve the reproductive health outcomes of women in Australia and beyond, and unbalanced reporting could negatively affect progress in this area.</p>
<p>Unintended pregnancies have an enormous impact on the economic, social, psychological and physical aspects of women’s lives. International consensus supports the safety and efficacy of LARC as the most effective public health strategy to address this.</p><img src="https://counter.theconversation.com/content/89074/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kirsten Black was part of a team that received funding from the National Health and Medical Council to conduct a randomised trial of LARC uptake in Australian women.</span></em></p>Long-acting reversible contraceptives are more reliable than other methods of contraception and most women are happy with them.Kirsten Black, Associate Professor & Joint Head of Discipline Obstetrics, Gynaecology and Neonatology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814532017-07-27T03:02:13Z2017-07-27T03:02:13ZContraceptive use in Nigeria is incredibly low. A lack of knowledge may be why<figure><img src="https://images.theconversation.com/files/179605/original/file-20170725-23039-xtft18.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Contraceptives lie at the heart of proper family planning but in Nigeria uptake has been slow.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The importance of <a href="https://www.usaid.gov/sites/default/files/documents/1864/Glob%20Health%20Sci%20Pract-2016-Starbird-GHSP-D-15-00374-508ct_final.pdf">family planning</a> in addressing a range of challenges in developing countries is now widely accepted. Family planning is a key factor in achieving the <a href="http://www.un.org/sustainabledevelopment/sustainable-development-goals/">Sustainable Development Goals</a>. And getting it right can help countries in meeting related targets such as education, particularly for women and girls.</p>
<p>If done properly it can <a href="http://www.urbangateway.org/sites/default/ugfiles/Levels,%20Trends%20and%20Differentials.pdf">prevent</a> unintended and high risk pregnancies that often lead to the deaths of mothers and babies. It’s important for other reasons too: it can reduce women’s dependency by allowing them more opportunities to work. And lower population growth, combined with a good political climate, can boost <a href="http://www.nature.com/news/development-slow-down-population-growth-1.19415">economic development</a>.</p>
<p>Contraceptives lie at the heart of proper family planning. But its use can be shaped by several factors. This includes cultural norms and values as well as the desires and decisions of couples. <a href="https://www.ncbi.nlm.nih.gov/pubmed/17140337">Myths and misconceptions</a> also play a role, including beliefs that people who use contraceptives end up with <a href="https://globaljournals.org/GJMR_Volume11/1-Contraceptive-Practices-Among-Women-in-Rural.pdf">health problems or permanent infertility</a>, or, at one extreme, that contraceptives reduce sexual urge, and at the other that they increase promiscuity among women. </p>
<p>Other contributing factors include low <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835625/">access to health care facilities</a> and the <a href="http://www.bioline.org.br/request?rh06037">patriarchal nature of societies</a>. </p>
<p>Nigeria has made no progress in improving the use of <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">contraceptives for the past 10 years</a>. Contraceptive use in the country is incredibly low. </p>
<p>The biggest contributor to the low uptake has been a lack of knowledge about the various available options, combined with misconceptions about the use of contraceptives. </p>
<p>But understanding what we mean by “knowledge” is key to unlocking Nigeria’s problem. We all accept that human behaviour is generally affected by what people know. A reasonable deduction would therefore be that knowledge about contraception should be an important predictor of contraceptive use. The reasonable assumption would be that the more people know about contraceptives, the more they would use them.</p>
<p>Nigeria’s <a href="http://microdata.worldbank.org/index.php/catalog/2014">2013 demographic health survey</a> showed that this isn’t the case. About 85% of women and 95% of men reported knowing a contraceptive method. But just 15% were using it. The unmet needs of women wishing to stop or delay births by not using contraception is 16%.</p>
<p>There’s nothing to suggest that the situation has improved since the 2013 report. This is clear from <a href="http://data.un.org/Data.aspx?q=Nigeria+growth&d=WDI&f=Indicator_Code%3ASP.POP.GROW%3BCountry_Code%3ANGA">Nigeria’s continued rates of population growth</a> as well as <a href="https://www.unicef.org/nigeria/children_1926.html">maternal and infant deaths</a>.</p>
<h2>Poor state of affairs in Nigeria</h2>
<p><a href="http://www.sciencedirect.com/science/article/pii/S0010782414006969">Only 15% of Nigerian women</a> aged 15-49 use contraception for limiting and spacing of birth. A Nigerian woman gives birth to an average of <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">5.5 children in her lifetime</a>. The country’s annual population <a href="http://data.un.org/Data.aspx?q=Nigeria+growth&d=WDI&f=Indicator_Code%3ASP.POP.GROW%3BCountry_Code%3ANGA">growth rate as at 2015 was 2.6%</a>. </p>
<p>Algeria provides a useful counterpoint. More than half – 57% – of married women are using contraception and a woman will give birth to an average of <a href="http://worldpopulationreview.com/countries/algeria-population/">3 children in her lifetime</a>. The north African country’s <a href="http://www.gdpinflation.com/2014/09/algeria-population-from-1960-to-2014.html">annual population growth rate is 1.89</a>. </p>
<p>In Sweden, contraceptive use is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439158/">75%</a>. A Swedish woman will give birth to an average of <a href="http://www.pregnantpause.org/numbers/fertility.htm">1.6 children</a> and the country’s <a href="http://data.worldbank.org/indicator/SP.POP.GROW">population growth rate is 1.1</a>.</p>
<p>So what is Nigeria doing wrong? And how can it be fixed?</p>
<h2>What’s missing</h2>
<p>Knowledge of contraception means knowing at least one of the methods. Modern contraceptive methods include female sterilisation, male sterilisation, the pill, the intrauterine device (IUD), injectables, implants, male condoms, female condoms, the diaphragm, foam/jelly, the lactational amenorrhea method, and traditional methods include periodic <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">abstinence and withdrawal</a>.</p>
<p>On average, a Nigerian woman or man aged 15-49 knows about <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">5 out of the 15 methods of contraceptives</a>. </p>
<p>On top of this, the most common methods cited were those that carry the highest risks of pregnancy. The most common method women cited was the pill (71%) which has a failure rate of 9% and can lead to nine <a href="https://www.ncbi.nlm.nih.gov/pubmed/22590895">unintended pregnancies</a> per one hundred women a year. </p>
<p>For men, the most common method cited was the male condom (91%), <a href="https://www.ghc.org/kbase/topic.jhtml?docId=hw190504spec">which has a failure rate of 18% </a>. This can lead to 18 unintended pregnancies per one hundred women in a year. </p>
<p>Among the least known methods by both men and women in Nigeria was the long acting reversible implants method which can last between three to five years for women who use it. <a href="http://www.arhp.org/Publications-and-Resources/Quick-Reference-Guide-for-Clinicians/choosing/Implant">Implants have a 0.05% failure rate</a>. However, only 17.9% men and 24.7% women knew about it. </p>
<h2>The consequences</h2>
<p>If Nigeria continues with the current trends in contraceptive use and fertility, the population will <a href="http://www.urbangateway.org/sites/default/ugfiles/Levels,%20Trends%20and%20Differentials.pdf">continue to grow exponentially in the next 10 to 20 years</a>. </p>
<p>The consequences of this will be profound. The population will be a highly dependent one with few productive and more dependent people because of the age structure of exponential population growth. Also, health inequities will worsen. Already limited infrastructure will be stretched while rapid urbanisation will shrink service provision, leading to further social and economic challenges.</p>
<p>Nigeria needs to urgently rethink family planning programmes. In particular, it needs to focus on ensuring that people know more about the array of available contraceptives, the most effective types and how they can access them.</p>
<p>An initiative like this should also aim to reduce perceptions based on myths and misconceptions. Algeria has successfully plugged family planning gaps using an <a href="http://countrystudies.us/algeria/61.htm">integrated approach</a> of contraceptives availability, educational campaigns and partnering with religious groups.</p>
<p>Only a concerted effort can turn the situation around in Nigeria and narrow the existing knowledge gap.</p><img src="https://counter.theconversation.com/content/81453/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Funke Fayehun does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nigeria must reduce its population growth to increase the quality of life for people in the country. A better knowledge of contraceptives can help achieve this.Funke Fayehun, Senior lecturer, University of Ibadan, University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/717392017-01-30T14:01:01Z2017-01-30T14:01:01ZCould a contraceptive app be as good as the pill?<figure><img src="https://images.theconversation.com/files/154742/original/image-20170130-7659-12456ih.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There’s a company that claims its smartphone fertility-tracking app is <a href="https://www.theguardian.com/lifeandstyle/2016/nov/07/natural-cycles-fertility-app-algorithm-replace-pill-contraception">as good as the pill</a> at preventing pregnancy. Women have long monitored their menstrual cycles as a method of contraception but this has often been seen as unreliable because of the <a href="https://www.plannedparenthood.org/learn/birth-control/fertility-awareness">practical difficulties</a> of sticking to the method consistently. So could <a href="https://www.naturalcycles.com/en/">Natural Cycles</a>, or other similar apps, really offer women a reliable, hormone-free way to avoid getting pregnant?</p>
<p>The basis for Natural Cycles’ claim is a study of 4,054 women aged 18 to 45 that was published in the <a href="http://www.tandfonline.com/doi/full/10.3109/13625187.2016.1154143">European Journal of Contraception & Reproductive Health Care</a>. It indicated that using the app for contraception resulted in about seven out of every 100 women falling pregnant each year. This included pregnancies that the researchers felt were due to mistakes by the users, a so—called “typical failure” rate of the method. This is similar to the “typical” failure rate of the combined oral contraceptive pill, which is about <a href="http://patient.info/doctor/combined-oral-contraceptive-pill-first-prescription">eight or nine women a year</a> and includes women who, from time to time, forgot to take the pill.</p>
<p>Among those women who used the app perfectly, around five out of every 1,000 became pregnant. The researchers found that ten out of the 143 pregnancies reported in the study were actually due to errors in the app, which caused it to misinform couples about when they were fertile. This is known as “method failure” and means unplanned pregnancy can happen even when the contraceptive is used perfectly. </p>
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<p>But again, this figure was similar to the “perfect use” failure rate for the pill, which is around three women out of 1,000 a year. So this means, that in both typical and perfect use, the study suggests the app really can be seen as as effective as the pill in preventing pregnancy.</p>
<p>So how does it work? Almost all smartphone apps of this kind rely not just on counting the time since a woman’s last period, like traditional methods, but also on monitoring the temperature of a woman’s body. The apps use this information to predict when she has ovulated and so when she is fertile or not.</p>
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<img alt="" src="https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154745/original/image-20170130-7672-nej6ky.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">No more pills?</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>This is possible because a woman’s temperature rises slightly (about 0.3°C) around the day of ovulation and remains slightly elevated throughout the rest of the cycle. The ovum (female egg) lives for only 24 hours or so, so a couple can have sex after this time in the woman’s menstrual cycle with <a href="http://www.webmd.com/infertility-and-reproduction/fertility-awareness#1">no risk of becoming pregnant</a>. Having sex before ovulation can lead to pregnancy because the sperm can survive in the uterus for up to six days. </p>
<p>This has been known for a long time and is the basis of fertility awareness methods of contraception, where a woman takes her temperature before getting out of bed each morning and keeps a chart to <a href="http://www.nhs.uk/Conditions/contraception-guide/Pages/natural-family-planning.aspx">determine when she is fertile</a>. But it is very hard to predict the exact day of ovulation as a woman’s cycle length can vary, especially if she is stressed. And it is difficult to accurately determine whether or not a woman’s body temperature has risen enough to reliably show she is ovulating.</p>
<p>This is where technology can help. Devices such as wristband thermometers can monitor a woman’s temperature constantly so she doesn’t need to remember to measure it each morning. And the algorithms of the smartphone app can do the work of charting and calculating <a href="https://www.naturalcycles.com/en/science">which are the fertile days</a>.</p>
<p>So why is the typical failure rate of the Natural Cycles app as high as 7%? Well another major problem with any fertility awareness method is that it means you can’t have sex for several days of the month, or you have to use other contraceptives such as condoms. The study authors found that just over half of the women who did fall pregnant recorded having unprotected sex during the fertile period. So while smartphone apps may provide encouragement, they can’t stop you from wanting to have sex altogether.</p><img src="https://counter.theconversation.com/content/71739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has received funding from Bayer. </span></em></p>New technology claims to offer an effective alternative to hormonal contraception.Susan Walker, Senior Research Fellow/ Senior Lecturer in Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/683752016-11-08T16:02:13Z2016-11-08T16:02:13ZWe won’t have a male contraceptive until we change our understanding of risk<figure><img src="https://images.theconversation.com/files/145025/original/image-20161108-16697-9loxg3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Worth the risk?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-409500925/stock-photo-extreme-closeup-man-face-taking-white-pill-mouth-view-swallowing-pills-and-smile.html?src=agw2dHDA8OJujvHxN263FQ-1-55">Shutterstock</a></span></figcaption></figure><p>A <a href="http://press.endocrine.org/doi/abs/10.1210/jc.2016-2141">recent paper</a> reported that an otherwise successful trial of a male contraceptive injection was halted early due to the concerns of a safety committee regarding adverse side effects, specifically acne, mood changes and depression. </p>
<p>There have been comments on social media and <a href="http://www.independent.co.uk/voices/male-contraceptive-injection-successful-trial-halted-a7384601.html">in the press</a> that female hormonal contraceptive methods often cause adverse side effects but are still considered suitable for use by healthy women. For example, another <a href="http://www.bbc.co.uk/news/health-37551855%E2%80%8B">recent study</a> showed increased rates of depression in women using both kinds of contraceptive pill, and mood changes are a common adverse effect reported by some women using hormonal methods. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"792878303958949888"}"></div></p>
<p>As one author in the The Conversation asked, would <a href="https://theconversation.com/why-the-male-pill-is-still-so-hard-to-swallow-68133">the female contraceptive pill ever be licensed today</a>? One has to wonder – is this apparent double standard of concern about side effects an example of sexism in plain sight?</p>
<p>It is <a href="http://www1.udel.edu/soc-bak/tammya/socDev/blum%20stracuzzi%20gender%20in%20prozac%20nation.pdf">sometimes argued</a> that the apparent lack of concern about female contraceptive side effects is due to a cultural belief that mood swings and depression are simply part and parcel of “femininity”, and of little note. Conversely, when they occur in men, they are viewed as illnesses or side effects, and are considered much less tolerable. There are some deep cultural truths in this view – but there is much more going on, too.</p>
<h2>Changing attitudes</h2>
<p>The female contraceptive pill was <a href="http://hansard.millbanksystems.com/commons/1961/dec/04/birth-control-pills#S5CV0650P0_19611204_HOC_160">first available in Britain in 1961</a> and the trials on it were carried out a few years before the 1964 <a href="http://www.wma.net/en/30publications/10policies/b3/">Declaration of Helsinki</a>, which set the basic ethical benchmark for drug trials. Since then, trial methodology has developed, making adverse effects more visible. Ethical sensitivity has also increased with the well-being of trial participants much more prominent in the research process. </p>
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<img alt="" src="https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=341&fit=crop&dpr=1 600w, https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=341&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=341&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=429&fit=crop&dpr=1 754w, https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=429&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/145027/original/image-20161108-16733-j41kcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=429&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Not without its dangers.</span>
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<p>Added to these developments is the perception that end users of drug products are now more likely to sue manufacturers than they were 60 years ago. Everyone is now much more concerned than they were with ensuring the risks of a drug are outweighed considerably by the benefits.</p>
<p>Contraceptive products present particular difficulties when it comes to balancing risks and benefits. Unlike drugs to treat disease, contraceptive methods are used predominantly by healthy people. So any adverse effect might be viewed as tipping the balance towards unacceptable risk. </p>
<p>But of course women use contraception because they wish not to become pregnant. For this reason, taking into account the <a href="http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregcomplications.htm">risks associated with pregnancy</a>, the risk-benefit balance, for a woman, is favourable for any contraceptive method whose risks to health are minor or rare. </p>
<p>This is because the risks of pregnancy to a woman’s health usually greatly outweigh the risks of hormonal contraceptive methods, providing the woman is healthy. But men do not bear the health risks of pregnancy. So in a purely biological sense, almost any risk associated with a male hormonal contraceptive method could be deemed unacceptable. </p>
<h2>Non-biological risks</h2>
<p>And therein lies the problem. Many men also wish fervently to avoid unwanted pregnancy. But for them the risk is social, relational, emotional and perhaps financial. While the balance of risks and benefits when applied to treatments for disease can be made on an individualist and biological basis, such reductionism is unhelpful in regards to male contraception. For in this context we are necessarily looking at a couple’s risk, and for men we must assess non-biological risks and benefits as well as clinical ones.</p>
<p>Ethical and risk-benefit calculations have not yet reached this degree of sophistication. There are sound ethical reasons to be wary of balancing risks for one person against benefits for another. After all, I could argue that the risk-benefit balance of you donating one of your kidneys to someone in renal failure is so obviously in favour of donation that it should be commonplace. Perhaps even a moral obligation. But that would be an ethically worrying conclusion.</p>
<p>Nonetheless, in the area of male contraception, where studies have shown both <a href="http://www.sciencedirect.com/science/article/pii/S0002937804001395">efficacy</a> and <a href="http://humrep.oxfordjournals.org/content/21/8/2033.full.pdf">acceptability</a>, it is necessary to move beyond an individualised, biological calculation of risk. This requires courage on behalf of researchers, regulators and safety committees. It requires common sense from manufacturers, lawyers and the legal system. But most of all it involves an open public conversation about risk, how it is measured and what the figures mean to an individual user or couple. If this is not undertaken, research into male contraception will remain stopped in its tracks.</p><img src="https://counter.theconversation.com/content/68375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Walker has previously received funding from Bayer for research into female intrauterine contraceptive methods. </span></em></p>Why research into male contraception keeps hitting the buffers.Susan Walker, Senior Research Fellow/ Senior Lecturer in Sexual Health, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/572612016-07-21T17:38:59Z2016-07-21T17:38:59ZThe search for answers to hormonal contraception’s role in HIV infection<figure><img src="https://images.theconversation.com/files/131412/original/image-20160721-32610-ftsewe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Injectable progestin contraceptives are particularly popular in sub-Saharan Africa.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>About 75% of HIV-infected people in sub-Saharan African between the ages of 15 and 24 <a href="http://science.sciencemag.org/content/sci/308/5728/1582.full.pdf">are women</a>. Many factors play a role in this gender imbalance. These include gender-based social disparity and a high prevalence of intergenerational sexual partnerships. </p>
<p>But research suggests certain types of hormonal contraceptives commonly used in this region could also play a role.</p>
<p>Injectable progestin contraceptives, like Depo-Provera, are particularly popular in <a href="http://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(14)71052-7.pdf">sub-Saharan Africa</a>. They are effective and convenient. Instead of taking a daily pill, women can receive Depo-Provera injections every three months. </p>
<p>But studies suggest that women using this specific type of contraceptive are more susceptible to HIV. Most recently <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70247-X/abstract">a large-scale study</a> conducted in Africa found women using injectable progestins were twice as likely to acquire HIV than women using no hormonal contraceptive. </p>
<p>This type of study cannot <em>prove</em> a particular type of contraceptive actually makes women more susceptible to infection, as it is just looking for an association between the two.</p>
<p>To really find out if contraceptives make women more susceptible to infection, you need to see how these drugs actually affect the systems that protect the body from infection. Such studies are more difficult to do in humans, so my colleagues and I decided to explore mouse models.</p>
<h2>What we learnt from mice</h2>
<p>We used mice to learn if Depo-Provera or levonorgestrel (LNG), a progestin used in hormonal intrauterine devices, affect the genital mucosal barrier. This barrier serves as a blockade to prevents virus and bacteria from infecting body tissues. In other words, it is a first line of defense against infection.</p>
<p>Epithelial cells on the surface of genital tract tissues are a vital part of this barrier. They are held tightly together by adhesion molecules that make it difficult for pathogens to penetrate tissue and establish infection. </p>
<p>But <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">we found</a> that mice treated with Depo-Provera or LNG have lower levels of several of these adhesion molecules. This means that genital epithelial cells aren’t held together as tightly, tissue becomes more permeable and virus more easily invades. </p>
<p>Our research shows these contraceptives increase mouse susceptibility to infection. But do similar changes in permeability also occur in women? </p>
<p>To find this out, we obtained cervical tissue from US women before and after they started using Depo-Provera. This showed Depo-Provera causes changes to adhesion molecules and tissue permeability <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">similar to those seen in mice</a>. </p>
<h2>Where do we go from here?</h2>
<p>Sexually transmitted infection and unplanned pregnancy are interconnected public health problems. Countries with a larger burden of infection typically also have higher infant and maternal mortality rates and a great need for <a href="http://www.ncbi.nlm.nih.gov/pubmed/23871397">effective contraception</a>. </p>
<p>Since Depo-Provera and LNG provide women with effective contraception, we wanted to learn if there are ways to counteract their ability to weaken the mucosal barrier. With this in mind, we also performed studies in which mice were treated with both Depo-Provera and oestrogen.</p>
<p>This combination strengthened the genital mucosal barrier and made mice <a href="http://www.ncbi.nlm.nih.gov/pubmed/27007679">less susceptible to virus infection</a>. It also suggests a scenario in which women would receive Depo-Provera and a vaginal ring that releases oestrogen and an antiviral microbicide. </p>
<p>Before this can happen, research is needed to determine if Depo-Provera and an oestrogen-releasing vaginal ring protect non-human primates from viral infection. If positive results are seen, the next logical step would be clinical trials that explore if similar approaches also reduce a woman’s risk of acquiring HIV.</p><img src="https://counter.theconversation.com/content/57261/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thomas L. Cherpes receives funding from the NICHD. </span></em></p>Studies have suggested that women using a particular kind of injectable contraceptive are more susceptible to HIV infection. Research in mice offers new insights.Thomas L. Cherpes, Associate Professor in the College of Medicine, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/518792016-02-26T04:02:47Z2016-02-26T04:02:47ZMyths and misconceptions stop African men from going for a vasectomy<figure><img src="https://images.theconversation.com/files/112713/original/image-20160224-16429-1w8smkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vasectomies allow fathers to have a more active role in family planning. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>In many parts of the world, family planning is still considered a woman’s responsibility. This has prevented men from being more involved in family decisions about fertility. But it has also limited their access to family planning services targeted at them.</p>
<p>A vasectomy, or male sterilisation, is considered one of the few fertility control methods that allows men to take personal responsibility for <a href="http://www.ncbi.nlm.nih.gov/pubmed/23144022">contraception</a>. </p>
<p>Global <a href="http://www.un.org/en/development/desa/population/publications/pdf/family/worldContraceptivePatternsWallChart2013.pdf">contraceptive patterns</a> for 2013 show that only 2.2% of the world’s men have had vasectomies. This is compared to female sterilisation which sits at 18.9%.</p>
<p>Countries with the highest vasectomy rates include Canada where 22% of men of reproductive age have had a vasectomy. This compares to the UK with 21%, New Zealand with 19.5% and the US with 11%. In Africa <a href="http://www.fhi360.org/sites/default/files/media/documents/no-scalpel-vasectomy-rwanda.pdf">0.1%</a> of men have undergone vasectomies. </p>
<p>But on the continent, vasectomies could be one of the most effective male birth control methods. They are inexpensive and could therefore have a major impact on sustainable development and population growth. But the procedure is misunderstood and as a result poorly used.</p>
<p>There is a knowledge gap about the vasectomy procedure as a family planning method in several African countries. Only 38% of women and <a href="http://dhsprogram.com/pubs/pdf/FR308/FR308.pdf">48% of men</a> in Kenya knew of a vasectomy for family planning. In Nigeria this figure dropped to only 16% of married women and <a href="http://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">27% of men</a> identified. In Liberia, this figure stood at <a href="http://dhsprogram.com/pubs/pdf/FR291/FR291.pdf">20%</a> for both married women and men. </p>
<p>For family planning to be effective <a href="http://www.ncbi.nlm.nih.gov/pubmed/25922638">emerging evidence</a> increasingly shows that men must both support women’s use of contraceptives and use male fertility control methods if necessary.</p>
<h2>A risk free procedure</h2>
<p>A vasectomy is an effective (and increasingly reversible) method of birth control. It involves clamping, cutting, or sealing the duct that conveys sperm from the testicle to the urethra.</p>
<p>It is a fairly quick, simple and straightforward procedure which lasts barely 30 minutes. It can be done in a doctor’s practice or clinic on an outpatient basis, and under local anaesthesia. There are also very few risks or <a href="http://www.ncbi.nlm.nih.gov/pubmed/6534499">complications</a>.</p>
<p>Very few vasectomies fail or go wrong. In very rare cases, the duct spontaneously reconnects. But only about 1 in every 500 women have an <a href="http://www.who.int/mediacentre/factsheets/fs351/en">unintended pregnancy</a> in the year after their partner has undergone a vasectomy.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/112716/original/image-20160224-32745-t94dqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Very few vasectomies fail or go wrong.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>A low uptake</h2>
<p>Despite all of this, the uptake of vasectomies in Africa remains consistently low. </p>
<p>In <a href="http://dhsprogram.com/pubs/pdf/fr229/fr229.pdf">Kenya</a> only one of the 24 125 married women who were surveyed said her husband had undergone a vasectomy. In <a href="http://dhsprogram.com/pubs/pdf/SR192/SR192.pdf">Senegal</a> and <a href="https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf">Nigeria</a> none of the married women surveyed said their husbands had undergone vasectomies. And only 0.01% of the men interviewed in <a href="https://dhsprogram.com/pubs/pdf/FR254/FR254.pdf">Zimbabwe</a> admitted having a vasectomy. </p>
<p>The low uptake derives from a number of factors. Our field research suggests that a major reason for this is the cultural belief that a man’s fertility belongs to the community as a whole. As a result, men who go for vasectomies risk stigma and contempt. There are several myths and misconceptions surrounding the procedure. These include: </p>
<ul>
<li><p>Local beliefs associating vasectomy with de-masculinisation, framing it in terms of castration</p></li>
<li><p>notions that vasectomy causes painful sex, weight gain and obesity among men, and makes men develop female features, such as breasts</p></li>
<li><p>fears that it would reduce their sex drive and sexual satisfaction </p></li>
</ul>
<p>In addition, another challenge is that few health and family planning providers on the continent offer vasectomy services or discuss it in family planning counselling sessions. One study in <a href="http://www.ncbi.nlm.nih.gov/pubmed/22282576">Nigeria</a> reflects that only 5.8% of doctors discussed vasectomies during counselling sessions.</p>
<p>In our project in western Kenya, we wanted to increase the knowledge and uptake of family planning services, including vasectomies.</p>
<p>When the project began there were no recorded cases of vasectomies. By the end of 2014, 118 vasectomies had been done. </p>
<p>Community health workers were meticulously trained to help local communities understand vasectomies, family planning and men’s role in reproductive and family health. The consistent and careful engagement using clear and accurate messages and information helped people accept the practice. </p>
<h2>Changing the mentality</h2>
<p>Our work promoting the uptake of family planning in western Kenya has raised critical lessons about vasectomies and male involvement in family planning in Africa.</p>
<p>The first lesson is that men can become more involved in fertility planning and childbearing decisions. It happens when they are supported to make a strong personal connection to the issue of family and reproductive health and well-being. </p>
<p>The second is that vasectomies will be accepted as a method of family planning when the myths and misconceptions surrounding it are systematically dispelled. </p>
<p>A third lesson is in the value of getting community male champions to popularise vasectomies. The few men who undergo vasectomies often do so secretly and are rarely willing to speak out in support of the practice. Locally respected and authoritative men must be identified and recruited to act as ambassadors of change challenging myths and misunderstandings and highlighting the benefits of the procedure.</p>
<p>It is also important that health care providers who can offer vasectomy counselling and procedures are available. When we started our project, few providers had the necessary skills to perform the procedure. By mid-2015, the project had trained over 100 health providers. </p>
<p>Efforts to improve the uptake of vasectomy in Africa will fail without the accompanying training of health professionals.</p>
<p>What is urgently needed is a bold and innovative plan to address misconceptions and change perceptions around the process, communicate its benefits and ensure there are adequate numbers of well trained providers to offer it.</p><img src="https://counter.theconversation.com/content/51879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chimaraoke Izugbara works for the African Population and Health Research Center. He receives funding from the Packard Foundation, Hewlett Foundation, Sida, MacArthur Foundation, and the Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Michael Mutua receives funding from the David and Lucile Packard Foundation for the data collection and staff time at African Population and Health Research Center. </span></em></p>Vasectomies could be an effective male birth control method in Africa but the procedure is misunderstood and therefore poorly used.Chimaraoke Izugbara, Head of Population Dynamics and Reproductive Health and Director of Research Capacity Strengthening, African Population and Health Research CenterMichael Mutua, Data analyst, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/448962015-09-27T19:21:30Z2015-09-27T19:21:30ZFew Australian women use long-acting contraceptives, despite their advantages<figure><img src="https://images.theconversation.com/files/95115/original/image-20150917-32615-chxckk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long-acting reversible contraception such as intrauterine devices don't require women who use them to do anything else to prevent pregnancy. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/mirkmirk/16670919389/">Sarah Mirk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Few Australian women use long-acting reversible contraception, despite its advantages over other methods. These contraceptives offer women long-term, cost-effective, “fit-and-forget” contraception.</p>
<p>Long-acting reversible contraception (LARC) includes intrauterine devices (IUDs) and implants that are usually inserted in the upper arm. In contrast to other commonly used contraceptives, such as the pill and condoms, LARC don’t require women who use them to do something to prevent pregnancy daily or every time they have sex. </p>
<p>Intervention is required only when a decision is made to stop their use, and <a href="http://dx.doi.org/10.1016/j.contraception.2006.09.010">fertility is restored</a> when the contraception is removed.</p>
<h2>Good but under-used</h2>
<p>This type of contraception is highly effective for between three and ten years. Women using these methods have <a href="http://www.ranzcog.edu.au/documents/doc_download/2050-long-acting-reversible-contraception-c-gyn-34.html">less chance of unintended pregnancy</a> compared to women using other contraceptives. </p>
<p>In fact, along with sterilisation, these are <a href="http://www.cdc.gov/reproductivehealth/unintendedpregnancy/contraception.htm#How-effective-are-birth-control-methods">the most effective means of contraception</a>. This is because unlike other methods – such as the oral contraceptive pill, diaphragm, rings and condoms – whose effectiveness depends on correct and consistent use, compliance isn’t an issue.</p>
<p>Long-acting contraception is <a href="http://whqlibdoc.who.int/hq/2008/WHO_RHR_08.19_eng.pdf.">suitable for most women</a> including the young, those who’ve never given birth, are breastfeeding or have recently given birth, and those with chronic health conditions. It’s also suitable for use just before menopause, and <a href="http://austinpublishinggroup.com/obstetrics-gynecology/fulltext/ajog-v1-id1027.php">appropriate</a> for women who should avoid oestrogen. </p>
<p>Despite these apparent benefits, <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our research</a> shows Australian women don’t use these contraceptive methods very much when compared to women in other high-income countries.</p>
<p>Even though most of the 1,131 Australian women <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">we surveyed</a> had heard of IUD and implants, only 4% to 8% reported using these methods compared with <a href="http://onlinelibrary.wiley.com.ezproxy.lib.monash.edu.au/doi/10.1363/46e1914/epdf">10% to 32% in Europe and 10% in the United States</a>. </p>
<p>On the whole, our respondents thought these contraceptive methods were unreliable and said they were unlikely to consider using them. The findings of <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our study</a> suggest women in Australia may not be using LARC due to misperceptions about side effects, suitability and cost. </p>
<h2>Possible misunderstandings</h2>
<p>Concerns about the side effects and safety of LARC may reflect <a href="http://dx.doi.org/10.5694/mja12.11832">women’s understanding of the risks of infection and infertility</a> associated with older intrauterine devices. But modern long-acting contraception has been developed to overcome these early problems. They’re <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31828b63a0">safe</a> and US studies show they have <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31821188ad">higher rates of continuation and satisfaction</a> than other contraceptive methods. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/95117/original/image-20150917-32615-ikky4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The effectiveness of long-acting contraceptive methods doesn’t depend on correct and consistent use.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/hey__paul/6980584656/">Hey Paul Studios/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Religious beliefs may also influence choice of contraception away from long-acting options. <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We found</a> women who said religion was important in their fertility choices were less likely to consider long-acting contraceptive methods as reliable. And they were less likely to consider using them. </p>
<p>What’s more, UK research also shows doctors may not comply with patient requests for certain methods of contraception because of <a href="http://jfprhc.bmj.com/content/34/1/47.long">their own personal religious beliefs</a>.</p>
<p>Interestingly, <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">our research team</a>, along with others in <a href="http://dx.doi.org/10.5694/mja14.00011">Australia</a> and the <a href="http://dx.doi.org/10.1097%2FAOG.0b013e31821188ad">United States</a>, found women who’ve had a pregnancy or an abortion are more likely to think long-acting contraception is reliable and consider using it. </p>
<p>It’s likely that women who have experienced a pregnancy or, especially, an abortion are more motivated to obtain more effective contraception and avoid further unintended pregnancies. And doctors are likely to pay greater attention to these women’s contraceptive needs. </p>
<h2>Myriad barriers</h2>
<p><a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We’ve also found</a> that <a href="http://dx.doi.org/10.1016/j.ajog.2012.02.014">men tend to have</a> less knowledge of these contraceptive methods and to perceive them as being <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">less reliable</a>. This is likely due to the fact that women are the primary users of LARC and that men may receive little contraception education. Still, the <a href="http://dx.doi.org/10.1016/j.contraception.2011.04.018">attitudes of male partners</a> are important predictors of contraceptive use. </p>
<p><a href="http://www.fpv.org.au/assets/LARCstatementSHFPAFINAL.pdf">The cost</a> of long-acting contraception could be a barrier for some Australian women. <a href="http://dx.doi.org/10.3109/13625187.2015.1052394">We found</a> women who lived in socioeconomically advantaged areas were more likely to think of these contraceptive methods as reliable and consider using them than women who lived in disadvantaged areas. </p>
<p>It may be that the former have better health and access to health services and products, as well as money to spend on contraception. While implants and IUDs are subsidised by the Pharmaceutical Benefits Scheme, there are high costs – paid by the patient – for the insertion procedure. But despite their high initial cost, long-acting contraceptives <a href="http://dx.doi.org/10.1016/j.contraception.2008.08.003">are not expensive over the longer term</a>. They cost about the same as the oral contraceptive pill over equivalent periods of use. </p>
<p><a href="http://dx.doi.org/10.1016/j.whi.2010.07.005">Doctors</a> may be reluctant to prescribe these types of contraceptives because of uncertainty about their suitability. And they may have not received training on insertion. Indeed, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23992177">a 2013 Australian study</a> concluded doctors’ beliefs were the most important barrier to women using these contraceptive methods. </p>
<p>To help women make the right contraceptive choice for their needs, we need to provide accurate, up-to-date information to them, their male partners and their doctors. And we need to ensure that cost doesn’t prevent a woman from using the contraceptive method best suited to her.</p><img src="https://counter.theconversation.com/content/44896/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors, including Sara Holton, are investigators on the 'Understanding fertility management in contemporary Australia' study which was supported by an Australian Research Council Linkage Project Grant (LP100200432) with funding and in-kind contributions from Family Planning Victoria, Melbourne IVF, The Royal Women’s Hospital, and the Victorian Department of Health</span></em></p><p class="fine-print"><em><span>Heather Rowe receives funding from the National Health and Medical Research Council, the Australian Government, the Australian Research Council, Australian Rotary Health, not-for profit organisations and philanthropic trusts. </span></em></p><p class="fine-print"><em><span>Jane Fisher currently receives funding from the National Health and Medical Research Council, the Australian Research Council, the Australian Department of Social Services, the Australian Department of Health, the Victorian Department of Health and Human Services, Jean Hailes for Women's Health, Family Planning Victoria, Women's Health Victoria, Monash Health, the Australian Federation of Medical Women, the Parenting Research Center, Melbourne IVF, Grand Challenges Canada, Australian Rotary Health; the L and H Hecht Trust, the Jack Brockhoff Foundation and the Prostate Cancer Foundation of Australia .
Jane Fisher is President-elect of the International Marce Society for Perinatal Mental Health, she chairs the Psychosocial and Epidemiological Research in Reproduction Group for the Royal Women’s Hospital and Melbourne IVF and sits on the Royal Women’s Hospital Research Committee (2003 -), the Epworth Healthcare Human Research Ethics Committee (2009-) and the Masada Private Hospital Patient Care Review Committee (2003-). She is a member of the NHMRC Mental Health and Parenting Expert Advisory Group (2014-) and of the International Board of Advisors, Research and Training Centre for Community Development Hanoi, Vietnam. She has been an invited temporary technical adviser to WHO Departments of Reproductive Health and Research, Mental Health and Substance Use and Maternal, Newborn, Child and Adolescent Health and Development since 2005.</span></em></p><p class="fine-print"><em><span>Maggie Kirkman receives funding from the Australian Research Council, the National Health and Medical Research Council, Jean Hailes for Women's Health, Family Planning Victoria, Women's Health Victoria, Monash Health, and the Australian Federation of Medical Women.</span></em></p>Few Australian women use long-acting reversible contraception, despite its advantages over other methods. These contraceptives offer women long-term, cost-effective, “fit-and-forget” contraception.Sara Holton, Research Fellow - Women's Health, Monash UniversityHeather Rowe, Senior Research Fellow, Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash UniversityJane Fisher, Professor & Director, Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash UniversityMaggie Kirkman, Senior Research Fellow, Jean Hailes, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.