When Ovulation Occurs
Rings and Patches
Rule #1 in not
getting pregnant: Don’t have sex.
It’s an interesting
(and fool-proof) approach to birth control, but it’s clearly
not for everybody. So what’s Rule #2?
It’s this: Don’t
have sex without contraceptives.
a more useful (and more practical) approach for more women than
Rule #1, or its corollary that you won’t get pregnant if you
hold an aspirin snugly between your knees on a date.
That’s also why
for years, the favored contraceptive for millions of women around
the world has been the Pill.
(No need to explain
what pill. Since word first leaked out about its development
in the late 1950’s, everybody’s known what pill as soon as you
mention the pill.)
Since oral contraceptives
are effective and easy to take, they’ve achieved great acceptance
as a birth control technique. In fact, until recently (and until
AIDS) many women considered the Pill the only way to stay non-pregnant.
And the Pill remains
awfully popular. In the year 2000, birth control pills were still
being taken by 10.4 million women in the United States, or 27
percent of the female population in their childbearing years.
That’s why we’ve
put together this booklet. Because in spite of its popularity,
the Pill has never been shown to be totally safe. And safer contraceptive
techniques have never been shown to be totally effective.
And with every
day seemingly bringing more bad news about AIDS and about who’s
at risk and why, it’s important that every woman have access
to information about birth control methods that provide the protection
we all need against pregnancy and AIDS.
So if you’re interested
in staying pregnancy-free and protected against AIDS, give a
listen — and some thought — to the points we raise in this
booklet. Then make the birth control decision that’s best for
Because all the
pills and implants and hormones in the world aren’t as powerful
— and as precious — as you are, and we want to help you keep
things that way.
So what is
the pill, anyway?
Actually, the Pill
is not any one thing, but several, depending on the exact blend
of synthetic hormones found in any particular preparation.
as anovulatory agents (since they block ovulation, or the release
of the egg cell by the ovary), oral contraceptives today fall
into two main groups: combination pills and mini-pills.
contain varying amounts of two synthetic hormones, progestin
and estrogen, while mini-pills contain smaller amounts of progestin
have been around, in one form or another since 1960, when the
first Pill was introduced. They are highly effective when used
as directed, with combination-type OC’s rated as slightly more
effective than mini-pills.
The two types of
pills are also taken differently. Combination pills are taken
for 21 consecutive days with a seven-day break before and during
menstruation, while mini-pills are taken every day.
Why two different
Mostly due to health
considerations. Combination pills contain a small amount of the
female hormone estrogen, which reduces spotting or breakthrough
However, many of
the health risks associated with oral contraceptives have been
linked to estrogen, which has led to the development of progestin-only
So how do
the pills work?
Before we can fully
answer that one, we’re first going to need to do a short review
of Sexual Physiology 101.
When a little girl
is born, her ovaries contain hundreds of thousands of tiny sacs,
called follicles, each of which contain an egg cell, or ovum.
But unlike males, who produce hundreds of billions of sperm cells
in their lives, only 400-500 of a woman’s follicles ever develop
When a follicle
matures, an egg cell is released which moves into the Fallopian
tube, where it either meets up with a sperm cell or it doesn’t,
and fertilization either does or does not occur.
The egg cell then
moves to the uterus where, if it’s been fertilized, it embeds
itself into the endometrium, the blood-rich lining of the uterus,
which provides a safe, supporting environment for an implanted
embryo. If the egg is unfertilized, both it and the endometrium
are washed away in the menstrual blood flow.
Sound simple so
It isn’t. Because
all aspects of ovulation are controlled by hormones, the most
important of which are estrogen and progesterone (which are both
secreted by the ovaries) and two pituitary hormones, follicle
stimulating hormone (FSH) and luteinizing hormone (LH).
This is where it
gets complicated. Because it’s the effects and interplay of these
hormones that provide the basis for ovulation-or the prevention
of ovulation, depending.
Depending on whether
you take the Pill or not.
the first week of the menstrual cycle, pituitary secretions of
FSH spur development of the follicle, which in turn increases
the growth and thickening of the uterine lining. Then, just when
the follicle is about to rupture (and release the egg), estrogen
levels drop, which causes the pituitary to increase levels of
LH, which triggers ovulation.
the now-ruptured follicle releases progesterone, which signals
the uterine lining to prepare itself for implantation of a fertilized
egg, if a fertilized egg comes along. If none shows up, both
estrogen and progesterone levels drop, and we’re back where we
Which brings us
to the point of this entire discussion: The Pill works to prevent
ovulation by mimicking some of the hormonal changes the body
goes through during pregnancy.
The estrogen in
combination pills prevents maturation of the egg by reducing
FSH output from the pituitary, while progestin (after it’s first
converted by the body into progesterone) blocks LH output and
unbalances the internal environment of the uterus so that sperm
are less mobile and less likely to survive for long periods of
time. In mini-pills, the progestin does it alone.
In a sense then,
oral contraceptives trick the body into believing it’s pregnant,
since the high levels of progesterone released in the body during
pregnancy prevent continued ovulation.
If progestin is
enough to prevent ovulation, why do some oral contraceptives
have estrogen in them at all?
Besides reducing breakthrough bleeding, estrogen also provides
something of a back-up system for increased pregnancy prevention.
As we said earlier,
the effectiveness of combination contraceptives is higher-rated
above 99 percent, compared to the mini-pills’ 97 percent rating.
Then again, fewer health concerns are associated with mini-pills
than are linked to combination oral contraceptives.
are linked to the combination pill?
There are several
— but not as many as there used to be.
the earliest forms of combination pills used high doses of estrogen
that eventually were found to produce an increased incidence
of circulatory disorders-abnormal blood clotting and phlebitis,
even heart attack and stroke.
To avoid these
dangers, manufacturers lowered levels of estrogen and added progestin
to the pills.
provide the pregnancy prevention benefits of the early Pill,
with fewer health risks for most users. However, women over 40
or those with a history of heart problems or stroke should still
consider alternative forms of birth control-particularly if they
But for most other
users, recent news about the Pill hasn’t been all that bad.
concerns, more than a dozen studies now show that using the Pill
is not linked with an increased risk of breast or cervical cancer.
The largest study, completed in 1986, goes even further, concluding
that oral contraceptives do not raise the risk of any cancer
in women under 45. And the Pill may protect against cancer of
the ovaries and uterus and block pelvic inflammatory disease.
Still, all the
news about the Pill isn’t good, either.
to the drugs include hypertension (or high blood pressure), increased
blood cholesterol levels, and gallbladder disease.
of estrogen and progesterone in a woman’s body can also pose
serious hazards to a developing embryo and, for this reason,
women who suspect they may be pregnant should stop use of the
Pill immediately and consult a physician.
A number of side
effects have also been tied to the Pill, including nausea, weight
gain, breast tenderness, headache, and depression.
On the other hand,
Pill users may also experience lighter and more regular periods
and less severe menstrual cramping.
So how do
you reduce the risk of problems?
You can do a lot
For one thing,
don’t smoke if you’re on the Pill. (A lot of people would say
don’t smoke at all, but we say if you do, at least don’t take
the Pill.) Smoking increases the risk of heart attack and cardiovascular
problems. This risk increases with age and higher levels of smoking.
You should also
see a physician regularly and have a pap smear done at least
once a year. Early intervention is critical to preventing the
health risks outlined above.
And to repeat,
women over 40 and women with a family history of cancer or heart
and circulatory problems should probably opt for another form
of birth control. The potential hazards simply seem too great
to justify the risk.
really apply to everybody?
problems have been linked to the Pill, the risk of serious complications
for most users is low.
One 10-year study
of 16,000 women reported that of the “young, adult, healthy,
white, middle-class” women tracked in the study, “the
risk of using oral contraceptives appears to be negligible.”
the answer to the question: To pill or not to pill?
That’s up to you-and
According to the
best evidence, the chances of encountering major health risks
linked to the Pill are slight, even “negligible.”
Still, even slight
risks should be taken into account when you consider your health
and well-being. Many women consider any risk too significant
to ignore and the declining number of users in recent years reflects
Also remember that
the Pill doesn’t protect against AIDS or other sexually-transmitted
diseases. And if you’re single and sexually-active, preventing
AIDS ought to be as important as preventing pregnancy.
If you’re in a
committed monogamous relationship, AIDS is probably less of a
concern and should be less of a factor in making up your mind
about the Pill.
That’s when it’s
important to remember that even given the risks associated with
Pill use, pregnancy still poses more risk to women’s health than
And given continuing
high levels of unplanned births, the Pill continues to have at
least one thing going for it: It works. Whether or not you want
it working for you is your own decision. But if you don’t, there
busy figuring out ways to not get pregnant for years before the
Pill came along, probably as long as we’ve known how to get pregnant
(and about the connection between the sex act and the eventual
patter of tiny — and then not-so-tiny-feet).
More than a few
of the methods discovered along the way work — at least they
do if you do them right. And most are reasonably safe.
Well, rhythm, for
openers. One of the oldest systematic approaches to preventing
pregnancy involves mastering the intricacies of the ovulation-menstrual
cycle and avoiding sex (or at least unprotected sex) during times
when conception is most likely.
This method, long
known as the rhythm method, is practiced by millions of women
— many of whom rely on it due to objections to other “unnatural”
forms of birth control.
In recent years,
an updated version of rhythm has become increasingly popular.
Known as fertility awareness or natural family planning, this
method is based on self-readings of temperature fluctuations
and other body changes to determine the precise time of ovulation.
rhythm all about?
a woman using the rhythm method aims at preventing pregnancy
by avoiding intercourse on days when conception is most likely.
what those days are exactly has traditionally been a tricky business
at best, and, at worst, time that could have been better spent
doing other, more ultimately useful things — like planning the
color of the nursery, for example, or shopping for baby clothes.
the ovulation-menstrual cycle is so different for so many women
that it’s difficult to say just when ovulation actually takes
But since a little
knowledge about some things is better than no knowledge at all,
it’s probably worth recounting exactly what does happen in our
bodies (and when) that makes all the pieces of the ovulation
puzzle come together.
So when does
Very good question. But to
answer it, we’ll need to take another short refresher of Sex
the menstrual cycle begins by ending the previous cycle. Day
1 thus marks the beginning of the new cycle by commemorating
what didn’t happen in the old, as the uterine lining is shed
with the menstrual blood flow, a process which ordinarily lasts
from Day 1 to Days 5, 6, or 7.
In Days 6-13, while
a new egg cell is developing in the ovaries, the endometrial
lining in the uterus is busily preparing itself for the potential
person that may come to reside there if conception happens this
Day 12, the egg is released by the ovary and begins its slow
descent down the Fallopian tube towards the uterus. If no sperm
meets the new egg along the way, the uterine lining begins to
break up (usually around Day 25) and by Day 28 the next cycle
Well it is and
it isn’t. Because while conception is most likely to occur somewhere
around the midpoint of the cycle, other factors enter into the
equation that make simple statements irrelevant, or worse, plainly
disastrous-that is, if you’re basing your family planning, and
your future, on them.
For one thing,
although ovulation usually takes place somewhere around Day 14,
the exact timing of the release of the egg may vary from woman
And when you consider
that the egg can be fertilized for up to 48 hours, and when you
include the fact that a sperm cell can survive in the womb and
Fallopian tubes for 48-72 hours after intercourse, you begin
to get an idea of exactly how tricky this rhythm business is
To cover all the
angles (and any irregularities along the way) a safe bet is to
consider yourself most pregnancy-prone from Day 9 to about Day
18, although conception can occur at any time, especially if
you have irregular periods.
And while the only
really reliable way of tracking the precise time of ovulation
is through regular checks of body temperature (body heat increases
slightly at the time of ovulation) or through changes in the
cervix, the safest bet is to say that most women are least likely
to become pregnant during or immediately before and after their
Even that rule
of thumb isn’t foolproof, but it’s probably better for some women
than no rule at all.
you got? Rhythm sounds pretty chance-y to me.
approach to pregnancy prevention that goes by the new-fangled
name of barrier contraception involves the notion that if you
keep sperm out of the promised land, you prevent conception -and
a nine-month tour of duty as a prospective mother.
The good news about
barrier contraception is that it works and, in the two main forms
it takes-condoms and diaphragms-it offers varying degrees of
protection against AIDS and other sexually-transmitted diseases.
start with condoms. They’re pretty basic.
pretty basic — as basic as you can get, almost.
And before AIDS
made them front page news, condoms were just another birth control
device–and, to most people, an old-fashioned one, at that.
Condoms were probably
the oldest form of barrier contraception. Although men in ancient
Egypt wore penile coverings some thousands of years ago, they
were probably intended more for ornamentation and protection
from insects (ouch!) than for birth control purposes.
And even contraception
was still probably only an incidental benefit to the original
purpose of condoms–which was to provide protection from the
ravages of then-incurable venereal diseases–when they were developed
in late-medieval Europe.
Still, it didn’t
take long for the secondary purpose of condoms to be seen as
every bit as important as their primary purpose, and for years
they’ve served as a standby birth control device for millions
of men– and women.
condoms have become a preferred means of birth control for reasons
unrelated to pregnancy prevention. That’s because condoms (particularly
when used with the spermicide nonoxynol-9) offer the best protection
around against AIDS and other sexuallytransmitted diseases.
come in a variety of colors, textures, and forms– ribbed, textured,
contoured, lubricated, and dry-but all of them fulfill the basic
requirement that they stand as a barrier between the egg cell
and the sperm-or an infected person and his or her partner.
Most are made of
sheer latex (about 25/ten-thousandths of an inches thick), although
others are made of animal membrane. All condoms sold in the United
States are tested electronically under government supervision.
Given recent improvements
in condom performance and design and given the fact that, when
used properly, they protect against both unwanted pregnancy and
disease, condoms are increasingly being used by women in search
of birth control alternatives. That they give men some measure
of responsibility in family planning hasn’t really escaped anyone’s
aren’t exactly perfect yet, either.
They can break
(especially when used with a petroleum-based lubricant, like
baby oil or Vaseline, which causes latex to stretch and break)
and they can result in spillage if the man isn’t careful when
he withdraws from the vagina.
But used as directed,
condoms offer a safe and effective option for both birth control
and disease prevention. The main problem with them is getting
a man to wear one-and that’s a problem that a smart woman can
resolve easily: by making a love game out of the ancient love-glove
So what about
The diaphragm is
another type of barrier contraceptive which is used by millions
The diaphragm itself
is a circular rubber dome that fits snugly against the cervix,
at the top of the vagina, and prevents conception in one of two
ways: by blocking passage of the sperm to the egg and by actively
destroying sperm when used with a spermicidal (spermkilling)
Even though the
diaphragm operates on the same basic principle as the condom,
it does offer one definite advantage over its male barriercontraception
The woman can take
responsibility for having the diaphragm in place and ready for
action, while condoms can be an if-ier proposition. Then again,
diaphragms offer less protection against AIDS.
So how do
I get a diaphragm?
The basic procedure
for being fitted for a diaphragm involves a short stop at a Planned
Parenthood clinic or a gynecologist’s office (if there every
really is such a thing as a “short stop” at a gynecologist’s
This is necessary
so that you can be sure the diaphragm you get is one that will
actually work for you, that it’s neither too large or too small,
and that you know how to properly insert and remove it.
If you decide to
use a diaphragm, be sure to read and understand all instructions
that come with it.
And remember: Diaphragms
should be inserted no more than two hours before sex and left
in place for at least six hours afterwards-so that the spermicide
has enough time to destroy all the sperm in the vagina.
a diaphragm in too long (usually more than 24 hours) can lead
to urinary tract infections and, in a few cases, to toxic shock
though, the diaphragm is an effective alternative to the Pill-one
that offers the simultaneous advantages of ease, portability,
And even though
the effectiveness rating of diaphragms is not quite as high as
the effectiveness rating of the Pill (about 95 percent), for
many women it’s quite high enough, thank you, and a lot less
Isn’t a cervical
cap the same as a diaphragm?
Like the diaphragm,
the cap is made of rubber and fits snugly over the cervix, protecting
as well as (some researchers say better than) the diaphragm.
Since it can be
left in the vagina longer than a diaphragm -up to 48 hours and
doesn’t need extra applications of jelly-the cervical cap carries
the added advantage of promoting romantic spontaneity. On the
minus side, the cap is difficult to insert and can irritate the
vagina, which, for many women cancels out any advantage over
what else is there?
Well, there are
always intra-uterine devices. An IUD is a small plastic device
that is inserted into the uterus, which, for some reason, prevents
barrier contraception devices and the Pill, it’s still an open
question exactly how intra-uterine devices work to prevent pregnancy.
But even though
no one really knows the precise mechanism involved, it has been
known for thousands of years that the presence of foreign objects
in the uterus prevents pregnancy, possibly by disrupting the
normal functioning of cells in the lining of the uterus, making
it inhospitable to both egg and sperm cells alike.
of how IUD’s work, everyone seems to agree that the small copper
and plastic devices do work, usually well and with minimal attention
Everyone also agrees
that IUD’s can have drawbacks; they can cause heavier cramping
during periods (particularly in the months immediately after
they’re first inserted) and they can cause infections, which
could lead to other problems, even eventual infertility.
It can be.
In fact, public
concern over the risk of health problems linked to IUD’s (including
the pelvic infections, infertility, and deaths caused by the
infamous Dalkon Shield™)-is a main reason why many IUD manufacturers
in the United States withdrew their products from the market
in the mid-1980s.
It’s also led to
new research on the IUD. One new type of IUD, which was introduced
in 1988, is expected to reduce the risk of problems and maintain
a high level of effectiveness.
Still, how well-and
how long-any IUD works depends largely upon the woman.
Studies show that
10 to 15 percent of all IUD users expel the device sometime during
the first year (which might account for the IUD’s estimated failure
rate of 6 percent), and that another 10 percent experience side
effects, such as cramps and bleeding between periods, severe
enough to warrant removal.
So why do
women use IUD’s if they’ve caused so many problems?
they don’t cause that many problems for most women.
And they are effective
and you never have to pause-and fumble through the nightstand
or your purse in the dark-to find one when you need one.
That’s why for
so many women (60 million, at last count, worldwide), the IUD
represents a near-perfect answer to the birth control question.
And, remember, if you’re sexually active with more than one partner,
IUD’s offer no protection at all against AIDS.
contraceptive foams and sponges? They don’t look so bad.
You’re right: They
don’t look so bad.
The problem with
them is they don’t always work that well, either.
Used alone, foams
and creams and their contraceptive cousins, vaginal suppositories
(small tablets you insert into the vagina just before intercourse)
have a high failure rate-a rate estimated at between 30 and 40
Used in combination
with other contraceptive methods (such as the condom), foams
and suppositories add an extra layer of protection against both
pregnancy and AIDS (the spermicide, nonoxynol-9 has been shown
to kill the AIDS virus) that certainly makes them worth the investment.
In other words,
they work, but if foams or suppositories are all you’re using,
someday you might just discover that they didn’t work as well
as you hoped they would.
Sponges are small,
spermicide-coated polyurethane cushions that nestle against the
neck of the vagina, blocking the cervix.
And while its manufacturer
claims the product combines a reasonably-high effectiveness rating
(85-90 percent) with a high level of convenience and safety,
all the evidence just isn’t in on the contraceptive sponge yet.
Still, some facts
about the sponge can’t be ignored. Some users have reported difficulties
in placing and removing the sponge and others have complained
of vaginal irritation.
In addition, studies
show that the contraceptive sponge may pose the same risk of
toxic shock syndrome associated with high-absorbency tampons-and
if those allegations are true, contraceptive sponges may eventually
join the rabbit’s foot and the soda-pop douche on the scrap heap
of discarded contraceptive theory.
But if you decide
to try the sponge, at least use it carefully and follow all the
Also bear in mind
that the sponge provides only limited protection against AIDS
and other forms of sexually-transmitted disease.
Rings & Patches
Is there anything
quite a few new options for women looking for safer, easier-to-use
contraceptives-many borrowing a trick or two from their more
popular sister, the Pill:
- Injections such as Depo-Provera®
(a 3-month shot of progesterone) or Lunelle® (a monthly hormone
injection combining estrogen and progesterone).
sold as Norplant® and Implanon®. These small capsules
are implanted under the skin, releasing small amounts of progesterone
continuously for five years.
IUD’s and vaginal rings.
Smaller and safer than the IUD-of-old, these new IUD’s, and the
recently approved vaginal ring (inserted for 3 weeks of each
cycle), release hormones directly to the reproductive system.
currently being tested and expected to gain FDA approval by the
end of 2001. Worn for seven days, three of these half-dollar-sized
patches are used during each cycle to release a combination of
estrogen and progesterone directly through the skin.
While each of these
options offer near-perfect (over 99 percent) protection against
pregnancy, they also can produce side effects similar to the
pill, including: irregular bleeding, irritability, temporary
weight gain, nausea and headaches.
And, again, none
of these new options offers any protection against sexually transmitted
diseases or AIDS when used by itself.
I do if my contraceptive fails?
Even with the best-laid
plans, accidents do happen. Condoms break. Diaphragms and pills
get forgotten. Withdrawal comes too late.
But there’s good
news here, too: Emergency contraception (or “morning after”
pills) has been available since 1996, although not always well
Morning after contraception
uses larger-than-normal doses of birth control pills to interrupt
ovulation, fertilization or the implanting of an already-fertilized
Effective in about
98 percent of uses, the one catch is that the pills must be prescribed
by a doctor within 72 hours after unprotected intercourse.
available for pregnancy prevention are things that don’t work
(like douching and wishing real hard) and we’re not even going
to try to list all the things that people have tried that didn’t
It would take forever,
and you can read some of them in Dear Abby or Ann Landers-usually
from girls who sign off “Just Married” or “Older
is an option, but a not-very-popular option, even among women
who have had them.
But abortions are
available (although not always to women under 18 without their
parents’ consent), and can involve a number of different procedures,
depending on how far along the pregnancy is.
Still, if you carefully
any of the birth control methods described in this booklet, abortions
can always remain a final birth control option that you never
have to use.
What about RU-486?
I’ve heard it called the “abortion pill.”
After a war of
words between birth-control advocates and the antiabortion lobby
that lasted years and played itself out in headlines and the
evening news, the U.S. Food and Drug Administration finally approved
the use of mifepristone and misoprostol (known collectively as
RU-486 and sold under the trade name Mifeprex®) to terminate
pregnancies, in September, 2000.
the first 7 weeks of pregnancy, the drug combination is effective
in 95 out of 100 uses.
Still, there are
drawbacks. The procedure is not without risk and requires medical
supervision by a doctor since the drugs can produce excessive
bleeding, severe cramping and nausea that require hospitalization.
the answer then? Which form of contraception is best?
The answer is that
there is no answer-no single answer, anyway. No birth control
technique ever devised is 100 percent effective or 100 percent
safe (except abstinence-and even that may cause its share of
emotional and psychological problems), so the choice facing today’s
woman is which contraceptive method seems most promising and
least threatening at the same time.
of what you decide about the approach to contraception that seems
best for you, remember to make a decision and make it carefully.
Talk it over with your doctor or with a counselor at a family
planning clinic, then make a choice and stick to it.
Because one thing
all of the birth control methods discussed in this booklet have
in common is that none of them work if they’re not followed exactly
or if they’re not used every time.
Another thing all
the different approaches to birth control we’ve discussed have
in common is that each is intended to give you a larger measure
of control over your life and the way you express your life in
love. And both life and love are precious-to paraphrase Emily
Dickinson, love is all we know of life and all we need to know.
And new life is
the most miraculous form of all that love takes in expressing
itself. It’s an act of creation-not just chemistry and biology-and
it’s something to enter into deliberately, consciously, and lovingly-when
you’re ready and the person you’re in love with is ready.
So until then,
think over the facts and make the choice that works best for
you. And if you want our advice, it’s this: Love carefully. We
think loving carefully is the best answer of all-to questions
about birth control or any other aspect of our lives.
Being in love is
the most important thing we ever do in our lives.
Do it carefully.
And do it well.
Want to know
control options, fertility or family planning:
- Planned Parenthood
Call toll-free 1-800-230-PLAN to locate your nearest Planned
On the web: www.plannedparenthood.org
- Sexuality Information
& Education Council of the U.S.
130 West 42nd Street, Suite 350
New York, NY 10036-7802
On the web: www.siecus.org
- Allan Guttmacher
1120 Connecticut Avenue, N.W. Suite 460
Washington, D.C. 20036
On the web: www.agi-usa.org
diseases and AIDS:
- American Social
P.O. Box 13827
Research Triangle Park, NC 27709
On the web: www.ashastd.org
- Do It Now Foundation
PO Box 27568
Tempe, AZ 85285-7568
On the web: www.doitnow.org
- U. S. Centers
for Disease Control
National STD Hotline: 1-800-227-8922
National AIDS Hotline: 1-800-342-AIDS
Information in Spanish: 1-800-344-SIDA2
On the web: www.cdc.gov/nchstp/dstd/dstdp.html