Contraception, Hormonal Methods and Surgery

The discovery of hormones in 1898 and subsequent developments in biological science during the twentieth century were necessary before hormonal methods of contraception could be made available. Physical barrier methods of birth control and douching after intercourse had been tried with varying degrees of success for centuries, but the idea of preventing pregnancy with a pill was a dream of such women’s health advocates as Margaret Sanger, founder of the Planned Parenthood clinic

The history of the development of oral contraceptives must include the work of scientists in Japan in 1924 and Austria in 1927 who devised what became known as the ‘‘rhythm method’’ of birth control. In independent research, both groups realized that a woman’s fertile period is approximately midway in the menstrual cycle (that is, counting from the first day of her period until the beginning of the next period) and that pregnancy could be avoided by abstaining from sex at that time.

The connection between hormone levels and ovulation was clearer when scientists at the University of Rochester in New York identified the ovarian hormone progesterone in 1928 and recognized its importance in preparing the uterus for the implantation and sustaining of pregnancy.

The next steps included the isolation of estrogen by Edward Doisy of Washington University, St. Louis, Missouri in the 1930s and the discovery of a way to make synthetic progesterone by chemical professor Russell Marker in 1941. This would become the basis for hormonal birth control. Following the Food and Drug Administration (FDA) approval of Enovid in 1957 as a treatment for severe menstrual disorders, it was only three years until the manufacturer Searle received FDA approval to market Enovid as an oral contraceptive, and it was quickly named ‘‘the pill.’’

Within five years over 6.5 million women were taking it, and oral contraceptives had become the most popular form of birth control in the U.S., resulting in a revolution in birth control technology that expanded women’s reproductive choices.

There are a number of hormonal contraceptives, including the combined pill; the progestin-only pill (POP), or minipill; hormonal injections such as Depo-Provera; contraceptive implants such as Norplant; patches such as Ortho-Evra; or the Nuvaring, a combination of the hormones estrogen and progestin. Each can be highly effective, if used according to instructions. Similarly, surgical methods such as tubal ligation for women or vasectomy for men can be equally effective, and both procedures became more widespread in the last three decades of the twentieth century.

Oral contraceptives (OCs) refer to pills containing both estrogen and progestin, although there are “minipills,’’ which contain only progestin. When taken consistently, pills can prevent ovulation, thereby eliminating the midcycle pain that some women experience at the time of ovulation. Pills can also decrease menstrual bleeding, thus decreasing the likelihood of iron deficiency anemia.

Birth control pills come in packs of either 21 ‘‘active’’ pills, or 28 pills, with 21 ‘‘active’’ pills and 7 placebo pills, designed to keep the user in the habit of taking a daily pill even during her period. It is also possible to prevent a cycle by taking extra pills from a separate package. Some forms of the pill have been proven to improve acne conditions.

Oral contraceptives have been determined to protect against some forms of cancer, including ovarian and endometrial cancer. In addition, the pill reduces anemia due to iron deficiency since it lessens the amount of blood lost during a woman’s menstrual cycle. Despite these positive effects, the pill does not protect users from sexually transmilled diseases, and the pill’s effectiveness rests on the user remembering to take to the pill every day.

Minipills, the progestin-only pills, are less effective than the combined OCs, since they completely change a woman’s menstrual cycle, which can lead to a bloated feeling or increased weight gain. These pills contain a lower dose of progestin, and no estrogen; for these pills to be effective, users must take them at the same time every day.

The progestin in these pills thickens the cervix mucus, making it difficult for sperm to enter the uterus or fallopian tubes. The risk for pregnancy is, however,greater for the minipill. For users of the combined pill, the risk of pregnancy is 3 percent, while for users of the minipill, the risk increases to 5 percent.

For those who have difficulty remembering to take the daily pill or for whom OCs are not recommended, there are other options, including Norplant, in which six 34-millimeter-long Silastic rods that release levonorgestrel are inserted into the woman’s upper arm in a fanlike shape just under the surface of the skin. This method, although effective, can be expensive. The erratic bleeding patterns that result also may not appeal to many women; approximately 60 percent of Norplant users report irregular bleeding patterns within the first year of use.

Depo Provera injections, which are administered in the arm or buttocks every 90 days, are highly effective and fairly inexpensive, with an average cost of $40 per injection. Women receive Depo injections every 13 weeks, with each injection containing progestin, which thickens the cervix mucus. However, Depo shots can cause the same side effects as the pill and Norplant, often resulting in headaches, weight gain, nervousness, and dizziness.

Depo shots have been proven to cause the most significant weight gain, with an average of 7.5 kilograms after six years of use. It is important that women receive these shots every 13 weeks for the shots to be effective; when used effectively, about 3 in 1000 will experience an unexpected pregnancy in the first year of use.

The most common surgical method of birth control for men is vasectomy. The procedure involves the removal of a portion of the vas deferens, thus resulting in male sterility; this procedure does not affect the male sex drive or ability to ejaculate. Less than 1 in 1000 couples will experience an unexpected pregnancy in the first year of sterilization; the sterility, however, is not immediate, and the male is still fertile for three months, or 20 ejaculations, after the completion of the vasectomy.

In the tubal ligation procedure for women, the fallopian tubes are tied off, and a section of each tube is removed, thus resulting in sterility. Eggs released from the ovaries each month are blocked from reaching the uterus, thereby preventing fertilization by sperm. Less than 1 in 100 couples will experience an unwanted pregnancy in the year following a tubal ligation.