Hey there, rad Femsplainers. This month we’re going to talk about birth control! No matter what your dreams are, being able to control if/when you or your partners get pregnant is a big part of making them happen. There are a lot of options out there and it can be difficult to know which one is right for you — which is why this article is a long one.
As a nurse (and someone who’s spent a lot of time counseling young women on birth control options), I wanted to create a list that’s comprehensive and also gives all of you access to all the knowledge and insight I’ve amassed over the years to help you decide which option is right for you.
(NOTE: I do not cover sterilization for cis women. It is a major surgery that can be difficult to get approved. If you think it may be something you’re interested in, talk to your healthcare provider about what your options are.)
I am a trans woman. Do I need birth control?
As a trans woman, you cannot get pregnant, but you were born with the body parts to produce sperm. If you still have all of those parts (a penis and testicles), even if you are taking estrogen you could still possibly get someone pregnant. When having sex with a partner who has a uterus an ovaries, one or both of you need a form of birth control to prevent pregnancy. If your partner is not using birth control, or you’re unsure if they are, condoms are your best bet (see Barrier Methods below for more info about condoms). Condoms are also great if you have more than one partner or a new partner because they also prevent STIs.
If you’ve had surgery to alter the genitals you were born with (i.e. an orchiectomy or vaginoplasty), you are no longer able to either make sperm, deliver sperm or both. In this case, you cannot get a partner pregnant.
I am a cis woman. What are my options?
There are a lot. Deciding which kind is right for you can be one of the hardest parts of getting started.
Hormonal Options
When used correctly, hormonal birth control pills are more than 99% effective.
All hormonal birth control options have a pretty similar side effect profile (although that does not mean that your body will react to them all the same way; it’s more about finding one that’s right for you). While many women have no problems at all while on hormonal birth control, systemically altering your body’s hormone levels can have some uncomfortable side effects. Some common ones include nausea, headache, weight gain, changes in sexual desire, changes in cramping or blood flow during your “period,” skin changes, breast tenderness and depression. Often, these symptoms resolve after one or two cycles. If they don’t, you and your healthcare practitioner may decide to try another birth control method.
It’s important to know that hormonal birth controls that contain an estrogen (esterone, estradiol or estriol) can affect the way your body processes fats and form blood clots. If you have high blood pressure, smoke, are over 35, have a history of blood clots, diabetes or high cholesterol, be sure to talk with your healthcare provider about whether or not an estrogen-containing birth control is right for you.
Estrogen-containing birth controls should also not be used by women who are breast-feeding, as it can inhibit milk production and pass estrogen through the milk to your baby. Progestin-only birth controls are recommended if you want to use a hormonal birth control while lactating. They can lose some of their effectiveness when mixed with certain medications, including some antibiotics, some seizure medications, some HIV medications and St. John’s Wort.
(NOTE: Hormonal birth control does not protect against STIs. If you have multiple partners, new partners or partners with an unknown disease status, be sure to also use a barrier method.)
The Pill
The classic birth control option. There is a lot to choose from if you go the pill route, but here are some things to keep in mind:
Some pills are progestin-only and some are combination-hormone pill. When taken exactly as directed, both types of pills have similar success rates. However, progestin-only pills, also known as mini-pills, have a lot less room for error — they need to be taken at the exact same time every day. Taking progestin-only pills even as little as three hours late can leave you as risk for pregnancy. Unlike combo pills, progestin-only pills also do not keep you from ovulating. They prevent pregnancy by thickening your cervical mucus, making it harder for sperm to enter the uterus and meet up with ready-to-be-fertilize eggs, and thinning the lining of the uterus. So why would anyone even take a progestin only pill? It can be a great option for women who can’t take a hormonal birth control that contains estrogen.
Combination pills, which have both estrogen and progestin in them, are more forgiving if you are not super great at taking pills at exactly the same time everyday. In fact, combo pills can protect you for up to three days if you forget to take them. The reason why is that in addition to thickening your cervical mucus, the combo pills also keep you from ovulating. In fact, the “period” you get when you are on combination pills isn’t even actually a period — your uterine lining never thickens or sheds like it would if you ovulated. Instead the bleeding that happens when you’re on combo pills is called “withdrawal bleeding” because it’s your body’s response to the sudden lack of hormones.
There are a lot of options when choosing a combination pill. Some have lower hormone levels (and as such fewer side effects), and some allow you to only have a few “periods” a year. If you decide try go the pill route, your doctor or friendly clinic nurse practitioner can help you decide which pill is right for you.
NuvaRing
If the idea of taking a pill everyday doesn’t sound right for you, there are several non-pill options! One of these options is the NuvaRing: a flexible, combination hormone-imbued ring that you insert into your vagina for three weeks. The ring is removed every three weeks to allow for a “period,” but for most women, another ring can be inserted immediately to bypass bleeding all together.
Much like a tampon, if inserted correctly, most women do not feel the ring, and generally, the ring stays in very well. And if it doesn’t, not to worry! If it’s not dirty, you can just rinse it off and re-insert it. Also it’s super fun to yell “you won the ring toss!” if it comes out on your partner or sex toy during sex.
Depo Provera
Depo Provera (Depo) is an injectable form of progestin. The injection is given once every 12 weeks and comes in two forms: the traditional intramuscular injection, and a newer, lose dose subcutaneous version. (Subcutaneous shots are injected below the skin, but not deep enough to be in the muscle.) Unlike progestin pills, Depo does inhibit ovulation, but like the pills, it is only as effective as combination birth controls when administered exactly on time. Because of this, real world effectiveness of Depo tends to be slightly less comparatively. (Three out of 100 women will get pregnant in a year, compared to less than one for combination birth controls.)
Depo can be a good, long-lasting choice for birth control. However, having worked at a teen clinic in which many of the young women were on Depo, I can say that anecdotally, the side effects tend to be more severe. Additionally, it has two major side effects that should be considered before deciding that Depo is right for you. First, for some women, it can take close to a year to begin ovulating after stopping. Second, Depo has been shown to lead to bone density loss. Because of this, the FDA suggests not taking Depo for more than two years. I, personally, would especially caution young women who have not reached their peak bone density yet to avoid Depo, if possible.
Nexplanon
Nexplanon (you may have also heard of the previous version, Implanon) is a progestin-only birth control option that’s implanted into your arm. It is a small rod that slowly releases hormones and can be left in for up to three years. Like progestin pills, Nexplanon prevents pregnancy by thickening cervical mucus and thinning the lining of the uterus.
Along with the side effects listed for all hormonal birth control, some women who use Nexplanon develop ovarian cysts. If you have diabetes, talk to your healthcare provider if you are considering Nexplanon. It can cause mild insulin resistance, which could affect your diabetes.
IUDs
IUDs, or intrauterine devices, are small T-shaped plastic devices that are inserted into the uterus to prevent pregnancy. There are three IUDs on the market: ParaGuard, Mirena and Skyla.
IUDs are highly effective (over 99%) because there is very little error in using them. It is, however, possible to expel the IUD and not feel it. All IUDs have a small length of wire that hangs down into the vagina. You can make sure the IUD is still in place by checking for the wire once a month.
IUDs can also be used as emergency contraception if inserted within five days of unprotected sex.
Before I go into how each of the IUDs work, I want to dispel a common misconception, one that even your healthcare provider might still believe. Way back in the 1970s, when IUDs were new, some women got pelvic inflammatory disease (PUD) after having an IUD inserted, and some of those women ended up unable to have children because of it. After this, it became standard practice to only insert IUDs in women who had already had children. What we now know is that the PUD was caused by those women having underlying vaginal infections that were not treated, and were then introduced into the uterus with the IUD insertion. If you are a woman with a uterus, not having kids is no longer a reason to not be able to get an IUD.
Pro tip: If you get an IUD inserted, plan to have it done while you are on your period. Your cervix will already be partially open (gotta let that blood out), making insertion easier. You can still expect to have the worst cramps of your life for a few hours after, though.
(NOTE: IUDs do not protect against STIs. If you have multiple partners, new partners or partners with an unknown disease status, be sure to also use a barrier method.)
Mirena/Skyla
Mirena and its baby sister Skyla are both hormonal IUDs. They slowly release progestin into the uterus, thickening cervical mucus and thinning the uterine lining. If using these IUDs, over time, you may also stop ovulating or getting your period. The Mirena can be left in for up to five years, while the smaller, easier to insert Skyla is good for up to three years.
ParaGuard
ParaGuard is the non-hormonal IUD option. It works by slowly releasing copper into the uterus, creating an inflammatory response that kills any sperm that enters the uterus. Because it does not stop ovulation, using ParaGuard does not stop your period, and may even increase cramping and bleeding.
Barrier Methods
Barrier methods can be great because unlike the previous methods we’ve discussed, some barrier methods also prevent the spread of STIs, as well as pregnancy. In fact, even if you are already using another form of birth control, barrier methods can be added into the mix for STI prevention. This is especially important if you have a new partner, multiple partners or a partner with an unknown STI status.
Barrier methods work by either preventing sperm from entering the vagina, or by preventing the sperm from entering the cervix.
If you’re going to be using a barrier method, remember: ALWAYS BE PREPARED. Barrier methods only work if you have them with you when having sex.
Barrier that prevent STDs
Condoms: Condoms are a great barrier method, in part because they are readily available. They can be found in most drug stores, grocery stores and convenience stores. If you don’t already know, condoms are worn on a penis and are typically made out of either latex or plastic. When used correctly, condoms are very effective at preventing both pregnancy (98%) and STIs. The key here is “used correctly.” First of all, the condom must be put on before there is any penis-vulva contact to ensure that no seminal fluid enters the vagina. One of the main ways that condoms fail is by breaking at the tip. You can prevent this by squeezing the tip of the condom as it is rolled onto the penis to prevent an air bubble there. When ejaculating, that air can cause enough pressure to tear the condom. After ejaculating, the penis must be pulled out of the vagina before it goes soft to avoid sperm spilling out of the condom. Always change the condom before having intercourse again.
Vaginal condoms: These are actually called female condoms, but the gendered name is unfortunate, so I’m renaming it. These condoms, like the ones mentioned above, keep bodily fluid from exchanging, preventing both pregnancy and STIs 95% of the time. These condoms work by inserting the closed end into the vagina (or anus for STI protection during anal sex) and leaving the open end hanging slightly outside of the vagina. Add lube and a penis, and voila! Sex!
Barrier Methods that do not prevent STIs
Barrier methods that do not prevent STIs include the sponge, cervical cap and diaphragm. They are inserted into the vagina to block entrance of sperm into the cervix. These methods are not nearly as effective as barrier methods at preventing pregnancy (cervical caps are only 71–86% effective, sponges are 88–91% effective and diaphragms are 88–94% effective), even when used with spermicide. Using spermicide with another of these methods is highly recommended.
Despite being less effective than condoms, sponges, diaphragms and cervical caps do have some advantages. If you know you are possibly going to be having sex, diaphragms and cervical caps can be inserted up to six hours prior to use, while the sponges can be inserted 30 hours ahead of time, and can be used for up to 24 hours without removal. Diaphragms and cervical caps are also reusable for up to two years, and despite an upfront cost of $75-$200 dollars, can be much less expensive than condoms over time.
Fertility Awareness and Withdrawal
These are considered to be natural birth control methods and require partners to know their bodies well.
Fertility Awareness
This is also known as Natural Family Planning. In this method, as the partner with a vagina, you keep track of your monthly cycle through counting days, daily basal temperatures and cervical mucus consistency to estimate when you are fertile, and then avoid having sex on those days. Generally, this method is only about 76% effective, but can be more effective the more disciplined you and your partner are about tracking fertility signs and abstaining from intercourse on your fertile days.
Withdrawal
Also known as the “pull out” method, withdrawal works by having the person with a penis pull out of the vagina prior to ejaculation. This requires that the person with the penis know their body well enough to know when they’ve reached the point where ejaculation cannot be held off any longer. When used consistently, withdrawal can be up to 96% effective. However, even one accident can lead to pregnancy, so this method is not recommended for couples in which the person with a penis is new to sex or unable to consistently know when it’s time to pull out.
