Melanie: There are several forms of hormonal contraception available today. Birth control pills, hormonal skin patches, implants, coils. They all affect hormone levels and prevent pregnancies, but they're used in different ways. How do you decide which form works the best for your needs?

Welcome to Conversations with MIT Medical. I'm Melanie Cole. And joining me today is Jennifer Shark. She's a certified nurse midwife at MIT Medical. Jennifer, it's a pleasure to have you join us again today. So, I'd like you to tell us about the birth control options. I mentioned just a few of them. Start by telling us how hormonal methods of contraception work to prevent pregnancy. What do they really do?

Jennifer Shark: Sure. So, most hormonal forms of birth control work by preventing ovulation. So when you're talking pills, patches, rings, and implants, that is what they do. They interrupt your ovaries from producing the hormones, which lead to ovulation.

Melanie: Okay. So, there are so many of these out there. Why don't you tell us about the options and how effective you feel each one is? Why don't you cover some of these options that are available today?

Jennifer Shark: Sure. So, the most effective systemic hormonal method of birth control is the Nexplanon contraceptive implant. This is a small matchstick-sized device that is inserted into the skin, just under the skin in the arm. It's a painless procedure and it is almost perfect contraception. It is greater than 99% effective. It has a very low failure rate because there is no user error and it can't get itself out of your body. So, it is one of the most effective forms of birth control that is still reversible. It is effective for three years and can be replaced as often as you want until you desire pregnancy.

Pills, patches and rings work very similarly and have similar efficacy rates. With perfect use, they're between 98% and 99% effective in preventing pregnancy. The way most people use birth control, it's about 93%, so about a 7% failure rate due to user error. So, people forgetting to take pills or change their ring or change their patch on time. So as far as pills, patches, and rings, they are all similar in efficacy. With perfect use, you get about 98% to 99% efficacy, so 1% to 2% failure rate. With the way most people use their birth control, it's closer to a 7% failure rate or 93% efficacy.

Pills are taken every day. There are several different ways that you can take birth control pills. So one way, the most common way people take birth control pills is a pill pack that has four weeks of pills; three weeks of active pills, and one week of a placebo pills. You take one pill every day, never missing a pill. And during the week when you're taking the placebo pills, that would typically be a time when you would have a period. You can also take pills so that you have periods less frequently. Many people do this for about 90 days at a time, so they take three pill packs, and take them all in a row without taking the placebos. And then every fourth pack, they take the placebo at the end of the fourth pack and have a period then. So, that's really popular for people who don't want to totally give up their period, but would like to have it less frequently for whatever reason. Then, there's also continuous pill-taking. You can take active pills every single day and skip your period forever. That is a less common way people like to take it, but there's absolutely no reason why you can't do this. Birth control pills only have placebo pills to make you have a period for a sense of normalcy, but it is completely fine to not have a period on birth control pills.

As far as patches, there is one birth control patch on the market today. It is a really nice method for people who want a hormonal method, but don't think that they can remember to take a pill every day. But taking a patch on and off once a week is not a problem at all. It works very similarly. It suppresses ovulation just like the pill. Patches are less popular because of the adhesive. Some people have a reaction to the adhesive. There's also a greater uptake of the hormone from the patches versus the pills, so you do get a higher circulating dose. And while that's not particularly dangerous, it can cause more side effects.

The vaginal ring contraceptive is also another really convenient way to get a hormonal birth control without having to take a pill every day. So, the ring is a soft, flexible, thin ring that is inserted into the vagina and is left in for 21 days and removed for seven. So, there's a seven-day ring-free interval when you would get your period. This can also be used as a continuous method of birth control by changing your ring every 21 to 28 days without having a ring-free interval. The contraceptive ring has the lowest dose of circulating hormone when it comes to the hormonal options, and so a lot of people really like it because it has often got fewer side effects than pills and patch. Some people feel uncomfortable putting something in their vagina, and so this would not be a great method for them, but it can be a really nice method for people who feel like a daily or weekly task is going to be kind of hard for them, but they could probably remember once a month.

Melanie: Well, thank you for going over all of those and also really looking at some of those factors that you would consider when determining a method of birth control that's right for you. Tell us a little bit about how you go about helping them select that contraception and for situations where you would just recommend a barrier contraceptive method and that that would be a better choice.

Jennifer Shark: Sure. When somebody wants some kind of contraceptive, it's really important to understand their health history. Most people can take these hormonal methods without any issues, but there are some medical concerns where taking a birth control method that has estrogen in it would not be a good idea. So if someone has migraine headaches with an aura, which means that you get like a visual or audio kind of prediction or predilection that a migraine is coming on, those people should not be taking estrogen because it increases their stroke risk. If you have a strong family history of a blood clotting disorder, we would want to make sure you don't have a blood clotting disorder before giving you anything with estrogen. People with high blood pressure should also not take birth control methods containing estrogen as it can make the blood pressure go even higher.

However, the Nexplanon, which we talked about earlier, does not have estrogen in it. It is only a progestin, which is a synthetic version of progesterone. And this is safe for most of those people. And so, it's a nice method for people who want a suppressive method of birth control, but who also cannot take estrogen.

So, all of these things really come from the patient's medical history. So, it's really important to sit down, talk to the patient, get a blood pressure reading, just to make sure everything is okay before considering estrogen-containing birth control methods. If they have no risk factors, then we can prescribe the pill, patch, or ring if that's what they desire. We can also do the Nexplanon implant. There's also, which we didn't mention earlier, there's the Depo-Provera injection, which is a progestin-only hormonal method that works similarly to the Nexplanon. It's just an injection instead of an implant. And that is also safe for people who cannot take estrogen.

You had asked about barrier methods. So, barrier methods can be excellent options for people who prefer to avoid hormones, whether they've had a bad experience with hormones in the past or they have that personal history of breast cancer or another estrogen receptor positive cancer, then barriers can be one of the good choices for those people.

It's really important to remember that pills, patches, rings, and implants do not provide protection against STIs. And so, if you're not in a monogamous relationship with a partner whose STI status you know, you should always be using a barrier in the form of condoms, either internal or external, with every act of sexual contact.

Melanie: What great information, Jennifer. So as we get ready to wrap up, what birth control options that you've gone over here today are covered by MIT's Student Health Insurance Plan and how can students get counseling to determine what form of contraception is best for them, how to properly use it and whether it's covered under their insurance.

Jennifer Shark: So if you have the MIT Student Health Insurance Plan, all of these methods are covered because you have not only a health insurance plan, but you also have a prescription benefit with that. So, these are available at no cost to students at MIT Medical. For students who have opted out of the MIT Health insurance Plan, whether or not they are covered depends on their parents' plan that they are covered under.

In terms of how to get counseling, how do you decide which form of birth control is best for you, we recommend that people come to either the OB-GYN department or the primary care department to have a visit for birth control counseling. And then, we go over all the different options, all the risks, the benefits, procedures, so that they can make an informed decision as to what is the best method of birth control for them.

Melanie: Thank you so much, Jennifer, for joining us today,

and And head over to our website@medical.mit.edu and search services, obstetrics and Gynecology, or Primary Care to get connected with one of our providers. That concludes this episode of Conversations with MIT Medical. I'm Melanie Cole.