According to a 2015 CNN report, a growing number of women, concerned about the side effects of the Pill, are turning to fertility awareness as their main method of birth control. Aided with technology from apps such as Kindra, Glow, and Ovuline, which help monitor primary fertility signs by tracking basal body temperature and cervical fluid, these women still represent a small portion of the population. However, a 2009 study published the Journal of the American Board of Family Medicine found that when given positive information about fertility awareness, more than one in five women expressed interest in using it. This research follows a 2007 article in Human Reproduction Today revealing that fertility awareness remains equally as effective as oral contraceptives, with none of the side effects.
No currently available form of birth control is 100 percent effective and riskfree, and no single method is right for everyone. A woman’s fertility is a highly personal matter, so the more you are able to feel in sync with your menstrual cycle and fertility, the better able you will be to make the right decisions about birth control for you and your partner. Despite scientific research, myths and misconceptions continue to abound. My goal in this chapter is not to join the debate but to make sure that the information already available to some in the alternative health community is available to everyone.
Fertility awareness, also called natural family planning, the Billings method (named after John and Evelyn Billings, two Australian researchers who helped popularize it), and mucus observation, among other names, is an underrated but extremely effective method of pregnancy prevention. This is not the old rhythm method promoted by the Catholic Church in the past, which was notoriously ineffective; each woman has her own “rhythm” that may change from time to time and may not fit into an established pattern.
Actually, fertility awareness can be characterized not as a method of birth control but as a way of life. That is, if you have a more accurate understanding of the dynamic physiological changes that occur during your menstrual cycles, you will be more aware of exactly when you are likely to get pregnant and will be better able to take preventive measures or, if you are trying to become pregnant, enhance your chances.
Some years ago researchers at Princeton University reanalyzed a mountain of data that had been collected by the World Health Organization (WHO) on couples who used fertility awareness. They found that this method was 97 percent effective in preventing pregnancy for those who understood its principles and used it as their sole method of contraception. This research should have put to rest the widely held myth that fertility awareness isn’t very effective.
Two myths that prevent many people from using fertility awareness as their main method of birth control are that it is difficult to learn and that women have to take their temperature every day and laboriously chart their menstrual cycles for the rest of their lives. This is definitely not the case. You can learn the basic principles of fertility awareness over a few months, and by knowing what to look for, you can learn to identify your fertile period intuitively with a high degree of accuracy without having to deal with charts and thermometers on a daily basis.
Essentially, a number of specific bodily changes signal the onset of a woman’s fertile time. These include changes in cervical mucus, body temperature, sexual desire, and an ovulatory pain called mittelschmerz (middle pain).
Getting pregnant requires three factors: sperm, alkaline fertile mucus to nurture and transport the sperm, and a ripe egg in one of the fallopian tubes. The menstrual cycle begins on the first day of menstrual bleeding, and the average cycle lasts twenty-seven to thirty days, although cycles as short as twenty-one days or as long as three to nine months are common. A viscous, “stretchy” mucous secretion manufactured in the glands of the cervical canal begins to ooze from the cervical opening at about day 10 of the average cycle and increases daily, peaking at days 14 to 16. Using a plastic speculum, you can actually see the clear mucus, which looks a lot like egg white, oozing from the cervical opening.
As production increases, the stretchy mucus seeps from the vagina and makes a sort of crusty secretion on your underpants or can be picked up by toilet paper.
At the same time that fertile mucus is beginning to develop, a ripe egg pops through the side of one of your ovaries and begins its trip of three to five days down the egg tube. As you approach ovulation, your temperature rises gradually and then, in most women, drops sharply on the day of actual ovulation. If fertile mucus is present and you have unprotected intercourse, the sperm slip easily along the liquid highway of mucus into the cervical canal, where they are kept alive for several days to regroup, as it were, and swim up through the uterus in search of an unfertilized egg.
The idea in using fertility awareness for contraception is to avoid having any sperm in the vagina at times when fertile mucus might be present. By carefully looking for the signs of ovulation (fertile mucus, a drop in temperature, mittelschmerz), you can identify pretty specifically when that time is. The first part of the cycle (including menstruation) is considered the “unsafe” time because fertile mucus can appear early or at low levels, but any fertile mucus presents the possibility of pregnancy. Couples who use fertility awareness as a form of birth control avoid vaginal intercourse at this time but may enjoy other forms of sexual activity. Others use a barrier method of contraception until they are sure that ovulation has occurred. After ovulation, however, another egg will not appear, so this is considered the “safe” time. After that time, according to researchers, it is perfectly safe to have vaginal intercourse without getting pregnant.
You can learn the tenets of fertility awareness from a number of excellent books, but many women and their partners find that taking a workshop with several sessions is the easiest and best way to learn. There is now a wide array of fertility detection devices that can be fun to use and are quite accurate.
Most birth control pills contain two types of synthetic female hormones, progestin (synthetic progesterone) and estrogen. In the first part of the menstrual cycle, higher-than-normal estrogen levels prevent the release of follicle-stimulating hormone (FSH). The absence of this hormone, which is manufactured in the pituitary gland, prevents an egg from developing inside the ovary. In the second part of the cycle, higher levels of progesterone thicken cervical mucus and inhibit the cyclic buildup of the uterine lining. If an egg were to be released or sperm were to get through the cervical mucus, the uterine lining would be too thin to support an implanted fertilized egg. The combination pills interfere with ovulation, thicken cervical mucus, and interfere with the buildup of the uterine lining.
Other varieties of pills also are available. Progestin-only pills, which are called minipills, are different in that they only thicken cervical mucus and interfere with the buildup of the uterine lining. Among the newer pills are Yaz, which contains a synthetic estrogen and drospirenone, a newer form of progestin; Seasonale, which contains progestin and estrogen and is taken for twelve weeks, followed by one week of placebo tablets, thereby causing menstruation only once every three months; and Lybel, the first continuous use birth control pill, which eliminates menstruation altogether.
In theory, the Pill is an elegant solution to the age-old problem of preventing unwanted pregnancies, and it has some positive aspects. Many women like the Pill because its use can be completely separated from sex and there is no mechanical barrier to be aware of during sexual activity. Because the Pill suppresses the menstrual cycle, its users often experience less painful menstrual cramps, fewer premenstrual syndrome (PMS) symptoms, and a lowered risk of anemia. Women with endometriosis may experience a decrease in pain and other symptoms, and those who have a tendency to develop ovarian cysts are less likely to do so. Studies also show a lower incidence of pelvic inflammatory disease caused by gonorrhea as well as cancer of the uterine lining (endometrial cancer) and ovarian cancer.
However, the Pill, even in its current lower-dose formulations, has some significant drawbacks. Higher-than-normal levels of hormones not only have the desired effect of preventing pregnancy but also travel through the bloodstream and affect other organs that have nothing to do with contraception, often precipitating or exacerbating serious underlying conditions. In addition, synthetic hormones can affect mood or exacerbate a tendency toward depression. They may decrease the desire for sex or cause hair loss or fatigue, a bloated feeling, and weight gain over time. Some women don’t experience any of these symptoms and enjoy the freedom from contraceptive jellies and devices, but others say that they simply don’t feel like themselves.
The Pill also interferes with the way vitamins are absorbed and utilized by the body. Dr. Sherrill Sellman, a naturopath, leading women’s health educator and writer, and author of Hormone Heresy, explains that it causes major nutritional deficiencies of the B vitamins and vitamins C and E, as well as mineral imbalances.
“The B vitamins are necessary to protect a woman’s immune system, her fertility, her emotional well-being,” she says. “The side effects from deficiency of these vitamins are fatigue, weakness, insomnia, aches and pains, weight loss, depression, irritability, lack of initiative, constipation, oversensitivity to noise, loss of appetite, circulatory problems, skin problems, gum disease, dizziness, depression, eye problems. Folic acid is an essential vitamin to help with the development of a healthy fetus. Women taking the Pill become deficient in folic acid. This compromises not just their own health and immunity, but also the health of their fetuses.”
Vitamins C and E are key nutrients for the immune system and the heart. They help detoxify heavy metals out of the body. “These are also seriously depleted in women who take the Pill,” Dr. Sellman says.
Mineral imbalances are not uncommon. “Copper goes way up and that causes migraine and hair loss and high blood pressure,” Dr. Sellman explains. “Zinc goes way down, which causes poor resistance to infection, diabetes, and infertility problems. The low-density lipids, the LDLs, go way up and the triglyceride levels also go up. So we are looking at serious, serious compromising of a woman’s health and her ability to function.”
One of the biggest problems that women have today with the Pill is fear that it may promote the growth of cancer. Medical studies on this issue are conflicting, but too many studies show an increased cancer risk to dismiss this issue. The National Cancer Institute reported in 2012 that while oral contraceptives appear to be associated with lower risks of endometrial and ovarian cancer, they appear to be linked with higher risks of breast, cervical, and liver cancer. In 2015, a study published in the British Journal of Clinical Pharmacology reported higher rates of a rare brain tumor in women using the contraceptive.
In addition to cancer, the Pill has been linked to other medical conditions. In 2015, research published in the BMJ (formerly the British Medical Journal) found that women taking newer forms of the Pill, brands such as Yaz, Yasmin, and Desogen, had triple the risk for blood clots than women not taking the medication. In 2014, a study presented at the American Academy of Neurology found that women who take the Pill may be as much as 50 percent more likely to develop multiple sclerosis.
About 10 million women in the United States use the Pill at any one time, but from 30 to 50 percent stop using it within a year because of undesirable side effects.
In the 1960s and 1970s high-dose pills caused serious problems for many women and are known to have caused a small number of deaths as well, but high doses equaled high effectiveness. The Pill got a reputation for being 98 percent effective. Today most women take the progesterone-only minipill, which is only about 96 percent effective in normal use. This is still quite acceptable in terms of effectiveness, but it’s not really much better than condoms, the cervical cap, or the diaphragm when those barrier methods are used consistently. Failures with minipills occur when women forget to take them or decide not to take them because they cease to be sexually active for a time. You can’t just take one pill and be protected; it takes several weeks for the hormones to build up in your system.
Other failures occur because of normal fluctuations in women’s hormone levels. You must take the minipill at the same time each day to get maximum protection. If you miss a day or two, double up on pills for at least two days. If you miss more than two days, you need to use another method, such as condoms or VCF.
There are numerous caveats you need to be aware of if you take birth control pills. You absolutely should not take the Pill if you have heart disease, severe varicose veins, serious circulatory problems, liver disease, or breast cancer. You should seriously consider using another method if you have diabetes, hypertension, gallbladder disease, depression, epilepsy, migraines, irregular periods, or sickle cell anemia—the trait or the disease. A woman with these conditions may take the minipill safely but should do so only after a consultation with her doctor. You should stop taking the Pill if you are planning surgery or must have your leg in a cast. The Pill may interfere with the absorption of certain vitamins—including vitamins B1, B2, B6, B12, C, and E and folic acid—and may alter carbo-hydrate metabolism. If you smoke, the Pill becomes far more risky for you.
Contraceptive Technology, a leading family-planning handbook, has devised an easily remembered acronym, ACHES, to help make you aware of the danger signs of the Pill:
A—abdominal pain (severe)
C—chest pain (severe), cough, shortness of breath
H—headache (severe), dizziness, weakness, numbness
E—eye problems (vision loss or blurring), speech problems
S—severe leg pain (calf or thigh)
If you experience any of these signs, call your doctor immediately.
In an article in the magazine Alternative Medicine, Dr. Jesse Hanley reminds women that being in touch with the natural monthly cycle of hormones supports their intuition and creativity, yet women’s lives today make it difficult for them to fully live out their female biological cycle. Taking birth control pills regulates their cycle to the point where they hardly notice that they’re having a period. As Dr. Hanley puts it, “Many women become almost addicted to not being a woman, to not understanding the natural cycling of hormones and the feelings, increased sensitivity, intuition, and creativity this evokes.” She sees this as a self-destructive tendency that will create health problems in the future. “Chinese medicine describes the uterus as the place where a woman’s energy and essence reside, so we need to rethink our approach to uterine health,” Dr. Hanley concludes.
Many people, both men and women, are reluctant to use condoms because direct skin-to-skin contact feels better. However, that thin rubber membrane may be all that stands between you and pregnancy or a variety of diseases. These latex rubber sheaths that unroll to cover the penis are 90 to 98 percent effective in preventing pregnancy. The effectiveness can be raised to nearly 100 percent by combining them with the cervical cap, diaphragm, vaginal contraceptive film (VCF), or fertility awareness.
Condoms also provide the best protection from sexually transmitted diseases (STDs). According to the US Food and Drug Administration, they are “highly effective” in preventing infection from HIV, gonorrhea, Chlamydia, trichomoniasis, and hepatitis B. They are less effective against genital herpes, human papillomavirus, syphilis, and chancroid.
Condoms are often thought of as a “male-controlled” method, but actually, the effective use of condoms requires the interest and willingness of both partners. Today both men and women buy condoms and keep them in their backpacks or at the bedside for ready use. Because of low cost and wide availability, condoms are the most commonly used barrier method in the world. They come in a variety of styles, in different sizes, and with various aesthetic embellishments, with or without lubricants and/or spermicide.
To be effective, condoms must be used correctly. They should be unrolled along the shaft of the penis with a little space left at the tip to collect the ejaculate. Condoms may be lubricated or can be used with a variety of water-based lubricants (read the label), but they should not be used with petroleum-based lubricants such as Vaseline. Removal must be done carefully to avoid spillage.
Because of rumors about a high breakage rate, many people believe that condoms are not all that effective. To counter those fears, the US Food and Drug Administration (FDA) has instituted more rigorous standards of testing, so breakage rarely occurs. Condoms that are old or have been exposed to heat are more likely to break. If you are worried about breakage, use two condoms at a time. Also, try to buy them in small quantities and at places where turnover is high, such as large discount drug stores.
The female condom somewhat resembles the standard male condom and can be bought over the counter. It is a soft pouch that is inserted into the vagina like a lining. It has two rings. One is fitted around the cervix like a diaphragm, and the other remains outside the body and covers the labia. If always used correctly, 5 out of 100 women will become pregnant each year. If not always used correctly, 21 out of 100 will become pregnant. It takes some learning to use properly, since it can get twisted if it is not inserted correctly. It may also reduce sexual sensation and the feeling of spontaneity.
The female condom is said to provide effective protection against STDs. It can be more effective in preventing pregnancy and disease if used with a spermicide. However, it has recently been found that spermicides have certain risks. In 2007, the FDA issued a warning that nonoxynol-9, the chemical ingredient in many spermicides, may irritate tissue and actually increase the risk of HIV infection and other STDs in certain individuals.
The diaphragm is considered a barrier method of birth control, but the spermicidal cream or jelly used with it is actually what kills the sperm and prevents them from entering the cervix. A diaphragm is a shallow cup made of soft latex rubber with a flexible rim that fits neatly into the palm of your hand. Once very popular, the diaphragm was overtaken in the early 1960s by the heavy promotion and the flood of research dollars behind the Pill. The diaphragm is made in a variety of sizes, ranging from about two to four inches (fifty to one hundred millimeters) so that it may be fitted in accordance with the length of the vagina. When it is in place, one part of the rim is lodged behind the pubic bone, while the opposite part cups underneath the cervix in the back of the vagina.
A diaphragm with spermicide can be inserted up to six hours before vaginapenis contact. It should stay in place for at least six hours after intercourse to ensure that most of the sperm are killed. The maximum amount of time the diaphragm should be left in is twenty-four hours. If you have repeated intercourse, it is necessary to insert more spermicidal jelly or cream with an applicator each time, leaving the diaphragm in place.
The diaphragm has few health risks. There is effectively no risk of it going farther inside than its correct position; if it pushes back against the rectum, it may be the wrong size. However, in addition to killing sperm, spermicide may kill off the lactobacilli in the vagina that keep yeast under control. To help counteract this, between diaphragm uses you can bathe with a solution of water and Lactobacillus acidophilus (available at most health food stores) by using a douche nozzle, a squirt bottle, or a plastic speculum.
About 20 percent of diaphragm users have occasional or recurrent bladder infections. This may occur because the rim bruises the urethra and makes it more susceptible to infection or because the spermicide alters the normal environment of the vagina and allows harmful bacteria to grow. If you are using the diaphragm and begin having recurrent bladder infections, you should look for a different method. If you have a prolapsed or otherwise displaced uterus, vaginal fistulas, or a protrusion of the bladder through the vaginal wall, the diaphragm is not an option for you.
As with other barrier methods, the diaphragm is effective only if you use it consistently and correctly. Studies have shown that the diaphragm is between 89 and 98 percent effective for women who use it during every session of intercourse (except during the menstrual period). However, the effectiveness of the diaphragm can be increased to nearly 100 percent by combining it with condoms or fertility awareness.
Your partner should not be able to feel the diaphragm, but if he does, it is usually only an awareness that something is there. Of course, using the diaphragm in no way compromises your fertility, and all you have to do if you choose to become pregnant is stop using it.
According to women’s health and sexuality advocate Rebecca Chalker, the existence of the cervical cap is one of the best-kept secrets of modern times. This is an approach to birth control that is as safe and effective as the diaphragm but offers a good measure of spontaneity and the convenience of the Pill.
The cervical cap is a small, silicone cup that is placed over the cervix in order to block the uterine opening. It is smaller and more compact than a diaphragm, and can be left in place for a longer time, up to forty-eight hours. As Chalker explains in The Complete Cervical Cap Guide, “a dollop of spermicide is placed in the dome. Then the cap rim is folded in half, tipped into the opening of the vagina, and guided with a finger to the back of the vaginal canal, where it readily slips over the cervix (the neck of the uterus). The cap stays firmly in place by gripping the cervix and forming a strong suction and provides a physical barrier to the sperm, while the spermicide affords an additional chemical barrier.”
Another well-kept contraceptive secret is vaginal contraceptive film (VCF). This square inch of material that looks like plastic but turns into a viscous liquid after five to fifteen minutes in the vagina is 28 percent nonoxynol-9, the sperm-killing ingredient in commercial spermicides. The film was designed to be used alone and seems to be about 85 to 90 percent effective when used that way, but most practitioners recommend that it be used with a cervical cap, diaphragm, or condom. Combining VCF with these barriers should increase their effectiveness to nearly 100 percent.
Some people find the higher dose of nonoxynol-9—about three times as strong as regular spermicide—irritating. If this happens to you, you will probably have to stop using it. The other disadvantage of VCF is that it is somewhat expensive and not widely available in the United States. However, it is less messy than normal spermicidal cream or jelly and provides a stronger dose of spermicide.
Implanon, approved by the FDA for use in the United States in 2006, is a matchstick-sized contraceptive implant that is inserted under the skin of the upper arm. It protects against pregnancy for up to three years by releasing a form of progestin that blocks ovulation. Implanon is similar to Norplant, which was taken off the US market in 2002. However, it has only a single rod instead of six.
The birth control patch (Ortho Evra) is a thin, plastic patch that sticks to the skin. It is placed on the skin once a week for three weeks in a row, and then removed for one week. The patch contains both estrogen and progestin. Some reports have linked the patch with an increased risk of breast cancer, among other adverse effects. In 2006, Johnson and Johnson recalled its patch after users were found to have three times more strokes and blood clots than the general population.
The birth control shot, also known as Depo-Provera, releases progestin into the body. Each shot prevents pregnancy for three months.
Dr. Hanley states that the synthetic hormones in these products can negatively interfere with women’s hormonal balance: “Some patients tell me that using this form of contraception makes them feel as if a black cloud has settled over them.” Other side effects may include irregular bleeding, weight gain, water retention, and depression. In addition, they may disrupt thyroid function and increase the risk of blood clots and cardiovascular disease.
According to the 2015 data from the National Center for Health Statistics, the use of IUDs in the US increased nearly five-fold in the last decade, becoming the contraceptive method of choice for 7 percent of women ages 15 to 44. IUDs are small, plastic T-shaped devices that are inserted into the uterus for varying periods of time. The ParaGard IUD, which contains copper, is effective for twelve years. The Mirena, Skyla, and newer Liletta IUDs, which release a small amount of progestin, are effective for five years. They work by blocking the passage of sperm, with the latter also blocking ovulation. There are benefits as well as risks and side effects associated with IUDs.
Many people are surprised to learn that surgical sterilization—tying, clipping, or cutting the fallopian tubes in women or cutting the vas deferens in men—is the most widely used form of contraception both in the United States and in the rest of the world. About 15 million women and men use this method.
Although it involves surgically altering parts of the body through snips and sutures, sterilization is the ultimate in “hands-off” birth control. Once the snips have healed, you never have to think about birth control again—unless, that is, you want to have a baby. Reversal rates for surgical sterilization are around 25 percent, depending on the type of procedure. This is a relatively low rate of success, and studies have found that regret is not uncommon among women and men who have had this procedure. Moreover, the surgery, which may not be covered by insurance, may cost thousands of dollars. Once again, no available form of birth control is without its drawbacks.
In women the surgery is most often done through a small incision below the navel. The abdominal cavity is inflated with carbon or nitrous oxide, and a laparoscope is inserted through the incision to allow the surgeon to see and manipulate the egg tubes with various instruments. This surgery is usually done on an outpatient basis, and a light general anesthesia or spinal block is commonly used. Most women have some abdominal discomfort for one to three days and feel fully recovered within a week.