Contraception and Family Planning

Natural Family Planning

There are many who are not able to use what have become the commonplace methods of contraception. Religious objections, physical side effects and intolerance, or threatening medical conditions often leave couples with no effective contraceptive methods. The Couple to Couple League, whose national office is in Cincinnati, has a manual called, The Art of Natural Family Planning. This book is a reference that is to be used with instruction by a couple trained to teach this natural method. There are no pills, no shots, no alterations of the woman's natural cycles. Instead, a technique called the Sympto-Thermal Method (STM) is used with virtually the same protection as the birth control pill. STM uses several indicators of fertility to make clear to a couple the fertile times that might indicate the need for abstinence.

Cervical mucus, physical changes in the cervix (mouth of the womb), and recordings of what's called the Basal Body Temperature (BBT) are all figured in with the woman's prior menstrual cycle history to "map out" the cycle. Both an internal and external mucus observation is used. An internal observation often precedes what is observed externally by two or three days. "Spinbarkeit" is the medical word to describe the elasticity of the cervical mucus around the time of ovulation. The more elastic the mucus seems to be, the more likely a woman is at the ovulation time.

Recent studies have demonstrated that the most likely fertile times are from six days before ovulation to the day of ovulation. The very next day fertility falls off incredibly fast.

Cervical mucus, in particular, the "last dry day," is cross-referenced with the slight temperature elevation that signals the second half of the cycle after ovulation. A special BBT thermometer is used to record the first waking oral temperatures. Progesterone, a hormone manufactured by the ovary after ovulation, is responsible for raising the temperature (usually by ½ to 1 degree). A clear advantage over the Billing's method which uses only the mucus method is that the temperature helps distinguish mid-cycle bleeding from a regular period. A regular period is preceded by a slight drop in the temperature. Indeed, a temperature shift that lasts twenty-one days can be a fairly reliable indication of pregnancy. Confusing blood-tinged discharge can indicate anything from ovulation to a yeast infection, so clearly the addition of the BBT adds an additional reassurance over the Billing's method. This is more than just the "rhythm" method. It is a double check system that is reliable, yet accomplishes many other things.

For one, it helps a couple understand the biology of the cycling woman. Another, it avoids the tampering with the system that birth control pills and other hormonal contraceptives use. It saves money, because it costs only for a thermometer. It also enhances intimacy, because it allows the man to relate to a woman's body in a privileged and respectful way.

In my practice, the couples who use the Sympto-Thermal Method taught by instructors associated with the Couple to Couple League have never turned up with a surprise pregnancy. But then, these are usually educated people dedicated to the method as well as to their marriage. Don't get me wrong, I think the birth control pill is an extremely important contraceptive; and I think newer techniques like Norplant (in spite of the bad press) and Depo-Provera add nicely to the choices available. Condoms, used correctly, offer a less reliable although still valid choice. But for women who cannot use these methods or who won't for philosophical reasons, STM is easy, readily available, and extremely useful.

The national office of the Couple to Couple League is 3621 Glenmore Avenue, P.O. Box 111184, Cincinnati, Ohio, 45211-1184, (513)-661-7612.

Does The Birth Control Pill Work By Magic?

Ideally, the birth control pill (more properly, the oral contraceptive) should act like magic: You just take a little pill everyday and you don't get pregnant. Simple.

It is far from magic, however; and unfortunately it is far from simple for some women. To understand how "The Pill" works, you must first understand a little about how you might become pregnant. The birth phenomenon is a very complicated one, and conception itself is the culmination of many different processes on many different levels.

One of the necessary conditions for conception, of course, is ovulation--the release of an egg for fertilization. This is the step that the oral contraceptive pill stops. The ovary is the small reproductive gland that releases an egg a month, ideally, for the purpose of fertilization. But the ovary itself is what we call an "end organ"; that is, it responds from stimuli elsewhere. It's the pituitary gland in the brain that calls the shots for the ovary. The pituitary sends Follicle Stimulating Hormone ("FSH," causes the egg to mature) and Luteinizing Hormone ("LH," helps the egg to be released) into the bloodstream so that the ovary as the end organ can respond. Ovulation occurs and what's left of the "luteinized" follicle in the ovary releases progesterone to ready the lining of the womb for implantation. When fertilization doesn't occur, the egg doesn't implant no matter how ready the lining of the womb is. This lining sloughs, which women experience as their period.

And it's not called a period for nothing: it is periodic. The period occurs when the hormones from the ovary, estrogen and progesterone, fall. And here begins the most amazing of the pituitary gland's magic tricks. Like a thermostat, it puts out FSH and LH when the estrogen and progesterone are low, and lowers production of these when the ovarian hormones are high. That is, when the ovarian hormones resulting in and from ovulation are high, the FSH and LH from the pituitary are low. When the ovarian hormones are low, the FSH and LH from the pituitary are churned out to remedy that situation by inducing ovulation. Things therefore go back and forth in the cyclic fashion known as the menstrual cycle.

The Pill prevents ovulation by acting above the belt rather than below it. In fact, above the neck, in the pituitary. The oral contraceptive has estrogen and progesterone in it. Taken daily to maintain steady blood levels, the pituitary in true thermostat fashion sees a lot of hormone and keeps low any FSH or LH. The woman doesn't ovulate. The last seven pills in the pack have no hormone in them, and the lining sloughs like it should, thereby mimicking the normal menstrual cycle but without the release of an egg. Contraception is achieved. The pill makes the body think it's already pregnant, temporarily at least, because a steady level of hormones circulate like what happens in pregnancy. Simple.

Not really. This is the ideal case. We must remember that the pill is a fixed dosage, but a woman's body is a dynamic functioning organism. Her body may need a certain amount of estrogen or progesterone to keep the womb's lining intact until her period. If the pill strength is too low (and we always start low first), the lining may be the type that needs more and irregular bleeding takes place. We gynecologists call this "break-through bleeding." Too strong a dose may lead to nausea and breast tenderness (just like in pregnancy). With dozens of formulations on the market, it usually is simply a trial-and-error method of finding just the right one for a particular patient. And even when we find the perfect one, the pill stays the same but the patient changes, and this perfect pill may no longer be so right for her later. The right pill for a woman over a period of time is often a jockeying for position as we change the prescription now and then for this reason or that. Patience is usually rewarded.

Because the full impact of hormonal life in a woman has yet to be completely understood, we often see strange effects in temperament as related to hormones. Certainly everyone is familiar with both PMS and menopausal mood changes. The wrong pill can also affect a woman's mood. I have seen marriages on the brink of divorce because of the wrong pill, only to be rescued by a change to another type. (See non-cyclic birth control pills.) Sexual desire, or libido, can be adversely affected or even enhanced.

But the beneficial effects of The Pill are numerous. Besides preventing pregnancy, it tends to "tame" horrible periods. Flow is less and cramping is improved, making it the drug of choice for adolescents missing school and suffering unreasonably each month. And--a big benefit--periods become regular, making it the drug of choice for women with irregular cycles. It also is the used as a treatment for cysts in the ovary. In short, there are many other things you can do with oral contraceptives beside contraceive!

Norplant Revisited

Norplant, a contraceptive method used successfully in other parts of the world for many years, finally received FDA approval in this country and was touted as the method of the 90's. It promised five years of pregnancy prevention, especially welcome to women who couldn't take the pill. Levonorgestrel, a female hormone, is released continuously in minute dosages through semiporous membranous capsules inserted through a needle in the underarm area. It works, doing exactly what it was designed to do--prevent pregnancy.

But then came the class action suits.

It seems that many women have complained of the known side-effects of Norplant. Irregular bleeding for many months and difficulty in removal have caused many to think of it as a problem contraceptive. This is unfair. Norplant is just one of many methods to prevent pregnancy. And all methods--when they work well, they work great! And when they don't work well, they can cause a lot of misery and inconvenience. The problem is that there is no blood test or fancy scan that can tell a doctor what's the best contraceptive for any individual patient. Contraception is pretty much trial and error. If a method doesn't work well, it's time to try another.

Similar to what's in Norplant is in a shot called Depo-Provera. A patient could get this shot every three months and have the same protection Norplant offers. But with the shot, she must keep getting them. With the Norplant, turnover is every five years. This is precisely why many women still get the Norplant: It is a proven method that'll last for five years. And if she happens to be one who has side effects she won't tolerate, it can be removed. But the most compelling reason women still seek Norplant, besides the contraceptive advantages, is that it can be inserted right after delivery while insurance or financial assistance is still in effect. Once someone's on her own for medical bills, Norplant was worth taking a small chance on if it'll save her sixty months of the cost of birth control pills, twenty Depo-Provera shots, or the hospital and surgeon cost of a sterilization procedure.

Every woman with a Norplant insertion scheduled needs to read the literature for it before the appointment. She needs to know that there will possibly be some lengthy irregular bleeding. She needs to prepare to be a good sport about this, or she really shouldn't get it.

Some women have the opposite problem--no periods. Most don't complain about this, but some don't feel "normal" unless they see a period every month. All patients need to know of these possibilities.

Removal is not that difficult. It just takes a little extra time. Most of the complaining actually comes from the doctor who's huffin' and puffin' trying to rush the procedure through a fifteen-minute time slot on a busy schedule. I learned long ago to leave a Norplant removal until the last appointment so that I can take my time, removal times varying anywhere from fifteen minutes to a half-hour.

Norplant is neither a panacea nor a bust. It is just one of many excellent methods that may not be for everyone. In this regard, it is no different from any other method, except abstinence.


The Intrauterine Device is a small T-shaped birth control apparatus that is placed into a woman's uterus to prevent pregnancy. IUDs have strings attached to the end that hang out of the cervix and allow women to check to make sure the device is in place. The IUD is a commonly used method of birth control.

The two most used types of IUDs are the hormonal IUD, known as Mirena, and the copper IUD, known as ParaGard.

The Mirena IUD can be used as a contraceptive method for up to five years. This IUD contains levonorgestrel, a synthetic progesterone hormone. This hormone does three essential things. First, small doses of the hormone are released into the wall of the uterus, which thickens the cervical mucus, making it hard for sperm to enter the uterus. Secondly, If an egg does become fertilized, the progesterone hormone prevents the egg from attaching to the lining of the uterus. Lastly, the progesterone hormone prevents ovulation.

The copper IUD, Paragard works much differently than the Mirena IUD. This IUD can be used to prevent pregnancy for up to 10 years. The Paragard IUD has copper wire wound around the stem and works by releasing copper ions. Copper ions are toxic for sperm and affect the way the sperm moves and prevent them from joining the egg. Copper ions also affect the lining of the uterus, preventing implantation if fertilization should occur.

As with most forms of birth control, there will be some side effects to deal with when using an IUD. The most common reactions users experience with Mirena are vaginal bleeding, amenorrhea, spotting between periods, ovarian cysts, and abdominal or pelvic pain. 

The most common side effects of ParaGard are heavier, longer periods and spotting between periods. Other side effects include the development of pelvic inflammatory disease, uterine perforation, anemia, vaginal infection or discharge, backache, faintness or pain. If you have questions about a side effect, be sure to check with your healthcare provider.

IUDs are a reliable form of contraception and is 99.9% effective after insertion, but pregnancies can happen if one is not adamant about checking to make sure the IUD is still in place, although the chance of getting pregnant is very low. IUDs can slide out without the user realizing it. Be sure to check for the IUD strings once a month after your period. It is very important to have your IUD removed soon after, if you begin to have pregnancy symptoms. In the long run, IUDs are the least expensive method of birth control, and do allow a woman to get pregnant later if she wants. Check with your health provider if you think an IUD may be the right method of birth control for you.

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