In the June issue of CHOICE in 1963, we heralded the arrival of the oral contraceptive pill to Australia: "The pill – one of the most effective methods of birth control – is now available in Australia on the prescription of a doctor." For the princely sum of 15 shillings, we offered our members a copy of The Consumers’ Union Report on Family Planning, "prepared for the use solely of doctors, clinics, social workers and married couples who are seeking such information on the advice of their doctors".
Half a century has passed since the pill hit our shores, yet it is still the most popular method of contraception. But what was true then is not true now. In practice, the pill is less effective than a large number of products now available on the market – the implant, IUDs and the injection all have higher efficacy rates. So why aren’t more people using alternatives to the pill? And what are the alternatives, anyway?
Long-acting reversible contraception
Aside from abstinence and sterilisation, the most effective forms of contraception are long-acting reversible contraception (LARC). According to one national survey, 50% of women in Australia experience an unplanned pregnancy, despite the fact that 70% of women use contraception. The solution, according to experts, is more women using LARCs, because unlike with other forms of contraception, human error has little impact on LARCs.
Name: Etonogestrel implant (implant), marketed as Implanon NXT in Australia.
Method: A 4cm-long, flexible plastic rod is inserted directly under the skin of a woman’s arm. The implant contains a synthetic hormone resembling progesterone, which is released continuously into the bloodstream for three years. Fertility returns very quickly upon removal.
Price: It costs about $35 for one implant, and is subsidised by the government on the Pharmaceutical Benefits Scheme (PBS).
Use: Lasts up to three years. Must be prescribed, inserted and removed by a doctor.
Efficacy: 99.95% with both perfect use (where all instructions are followed exactly) and typical use (which is how most women tend to use it).
Potential side effects: Some women with the implant will experience a dramatic change to their menstrual cycle (or other hormone-related side effects), but experts say women should trial the implant for three months and discuss issues with a doctor before considering removal.
The implant is the most effective contraceptive option available – it's even more effective than permanent contraception such as vasectomies, female tubal occlusions and ligations.
Although implants came onto the Australian market in 2001, the old Implanon was replaced by Implanon NXT in 2011. The difference is in the applicator, which is designed to minimise deep insertions leading to difficult and potentially risky removals.
There is no need for an incision when inserting the Implanon NXT. Upon insertion, there's a slight sting and some women may suffer from bruising afterwards. At removal, a two-millimetre incision is made. There's a very small risk of scarring, but this generally only affects people who have a tendency to scar.
Name: Levonorgestrel IUD (hormonal IUD), known in Australia as Mirena.
Method: A small piece of T-shaped plastic is inserted into the uterus. Fine threads attached to it protrude through the cervix, making removal easier. It slowly releases the progestogen-like hormone levonorgestrel for up to five years. Fertility returns very quickly upon removal.
Price: It costs about $35 for one IUD, and is available on the PBS.
Use: It lasts for up to five years. It must be prescribed, inserted and removed by a doctor.
Efficacy: (perfect and typical use): 99.8%
Side effects: In five per cent of cases, women may experience an unexpected expulsion of the device. However, women can check whether the device is still in place by feeling for the threads high up in their vagina, something the doctor who inserts the IUD should teach them to do.
Modern IUDs suffer from being tarred with the same brush as their earlier counterparts, with experts blaming a lack of information among women and GPs. Historically, IUDs have had a bad reputation but today's IUDs are very different from earlier iterations.
"The latest devices are a far cry from earlier prototypes," says Dr Deborah Bateson, medical director of Family Planning NSW and spokesperson for Sexual Health and Family Planning Australia. "There is a very low risk of pelvic infection, which is mainly confined to the first 20 days after insertion. There's no evidence of an increased risk of subsequent infertility for women using an IUD."
The insertion procedure is generally done by a GP or gynaecologist with experience in insertion, and is relatively brief and painless.
"We get women to take a painkiller beforehand, and most find it’s OK," says Bateson. "There can be cramping pain when the IUD goes in, and women who haven't had children - or those who have had C-sections - may have more cramping discomfort."
"While more commonly used by women who've completed their family or are spacing pregnancies, they are also useful for younger, [childless] women. They're [particularly] useful for women with heavy menstrual bleeding."
Like the contraceptive pill and the implant, Mirena can be used to treat excessive menstrual bleeding or protect against endometrial hyperplasia (excessive growth of the lining of the womb). As with the implant, the menstrual cycle is altered by Mirena, but women usually end up with lighter periods.
And a randomised trial of 571 women showed that Mirena is more effective than usual medical treatment in reducing the effect of heavy menstrual bleeding on quality of life. The trial, conducted by the University of Birmingham in the UK, also found that there were no significant differences in serious adverse events between groups using the IUD and those receiving conventional treatment.
Interestingly, a new "mini Mirena" may soon be available in Australia, according to our experts. "We have been trialling it," says Bateson. "It's smaller, [and] lasts up to three years. It might be useful for younger women with smaller uteruses, or women who’ve experienced side effects from other IUDs."
There have also been advances in more short-term contraception, with an injectable contraceptive, a large variety of pills and a female condom all on the market. These methods, however, rely more on the individual, and so tend to suffer from lower efficacy rates.
Name: Depot medroxyprogesterone acetate injection, marketed in Australia as Depo-Provera or the generic Depo-Ralovera.
Method: A synthetic hormone similar to progesterone is injected by a doctor or nurse every 12 weeks.
Price: Each injection costs about $26-$30, depending on brand.
Use: It is injected into the buttock or upper arm of a woman, and takes seven days to become effective. It is not immediately reversible, and women can take up to two years to return to full fertility.
Efficacy: 94% with typical use, 99.8% with perfect use.
Side effects: The injection has an effect on bone density. But for women in their mid-reproductive years, that reduction in bone density is reversible once they stop having the injection.
For women under the age of 18 or over 45, the contraceptive injection is not a first choice due to bone density side effects. However, Bateson says it can be a useful option for some women. "One advantage for some women is after using the injection for one year, 50% of women have no bleeding, and that percentage increases over time."
Name: Contraceptive hormone vaginal ring, marketed in Australia as NuvaRing.
Method: A soft, plastic ring is inserted by a woman into her vagina. Once inserted, it releases low doses of oestrogen and a progestogen, the same hormones found in the combined oral contraceptive.
Price: About $25 per ring.
Use: Once inserted, the ring remains in place for three weeks, and must then be replaced, either in one week after a withdrawal bleed, or immediately to avoid menstruation. The ring is prescribed by a GP.
Efficacy: 91% with typical use, 99.7% with perfect use.
"It’s an alternative delivery system to the pill," says Bateson. "The benefit is you don’t have to remember to take a pill every day. It appears to be relatively beneficial for cycle control, and it’s good for women who have breakthrough bleeding with the pill. However, the downside is it’s not on the PBS so cost may be an issue."
Another advantage of the NuvaRing is that, unlike the pill, vomiting and diarrhoea does not reduce its effectiveness as the hormones aren't absorbed in the intestinal tract.
Name: Combined and progestogen-only (mini) oral contraceptive pills, marketed under various brand names including Yasmin, Yaz, Diane 35, Isabelle, Levlen, Microval and many others in Australia.
Method: Most combined pill packs contain 21 active pills and seven inactive placebo pills, which allow women to menstruate. Each mini pill pack contains 28 active pills. There is leeway of up to 24 hours if a combination pill is missed, or just three for a progesterone-only pill, after which time a woman may no longer be protected against pregnancy.
Price: From about $35 to $283 for a year's supply.
Efficacy: 91% with typical use, 99.7% with perfect use.
The contraceptive pill is the most common form of contraception used in Australia. "We've got a lot of data on [the pill]", says Bateson. "It can be useful for controlling acne, managing heavy periods and decreasing period pain. Sometimes the pill can control headaches that some women get with their periods."
One of the main benefits of the combined contraceptive pill is the ability it gives women to control their menstrual cycle by skipping the placebo pills. "We now have plenty of data to show that it’s safe to have continuous pill use for up to one year. Some women will get breakthrough bleeding with prolonged use, so we sometimes advise three-month cycling."
Gastric upsets and certain medication can impact on the effectiveness of the pill, as can human error.
Yasmin and Yaz controversy
There have been reports of serious adverse health effects and even deaths around the world as a result of use of Yasmin and Yaz (and their generic dopplegangers). According to Canada's CBC News , these birth-control pills have been contributors to the deaths of 23 women in that country. A class action has been filed against Bayer, the manufacturer of the pills, in Canada, alleging that the company failed to adequately warn patients and doctors of the pills’ association with increased risk of stroke, deep vein thrombosis, pulmonary embolism, heart attack, gall bladder disease and/or removal when compared to other oral contraceptives. There are also reports of thousands of lawsuits against Bayer in the US.
Australian firm Tindall Gask Bentley Lawyers have announced that they are investigating the potential for a class action for women who use the contraceptives here. According to the firm, "The ingredient in question is the hormone Drospirenone. Pharmaceutical company Bayer, the maker of Yasmin and Yaz, may have misrepresented the risks of harm arising from using either of these tablets. Around 200,000 Australian women are believed to be using Yasmin and Yaz, which is now the subject of a number of class actions worldwide."
Australian women who believe they may have been adversely affected by Yasmin or Yaz can now register for the potential class action.
Emergency contraception is now available over the counter – useful in cases when contraception is forgotten or may have failed.
The most common emergency contraceptive method is a single 1.5mg dose of levonorgestrel taken within three days of unprotected penetration. It can be used up to five days after, but its effectiveness may be reduced.
Experts tell CHOICE that the emergency contraceptive pill is safe and there are no contra-indications as a result of taking it.
Copper IUDs may also be used for emergency contraception up to five days after unprotected sex.
Aside from these newer forms of contraception, there are other options that may be suitable.
The diaphragm is still favoured by some women, despite its relative lack of efficacy. With perfect use, it is 94% effective. With typical use, that figure drops to 88%.
Female condoms, which can be difficult to find, can be used by those with latex allergies and allow women to protect themselves against STIs. But at about $3 each they’re relatively expensive and their typical-use efficacy rate is low, so they should be used in conjunction with more effective contraception to prevent pregnancy.
Withdrawal and fertility awareness (timing of the cycle, temperature-taking) are also less effective forms of contraception. Although with perfect use their efficacy can be high, it drops significantly with typical use – just 78% for withdrawal, and 76% for fertility awareness.
Popular in the past, copper IUDs are also still available on the market. They may be suitable for women requiring an effective, long-acting, hormone-free method of contraception.
Work on a hormonal male contraceptive is ongoing. Most temporary methods involve blocking sperm. The trouble is, they also block testosterone which needs to be replaced, and men haven't appeared to be receptive to the method.
Researchers in the US believe they have discovered a compound that may be used to make the first hormone-free contraceptive pill for men. The researchers have developed a small molecule that in mice blocks the cell division necessary for normal sperm production, says Professor Robert McLachlan, director of clinical research at Prince Henry’s Institute of Medical Research.
According to the researchers, the drug has no significant side effects. However, it is in early stages of development and may take 15 years to become available for human use.
In the meantime, there are male condoms. Condoms have an efficacy rate of 82% with typical use, and 98% with perfect use.
Their high failure rate is mainly attributed to incorrect or non-use, or condom failure such as breakage. They provide good (but not 100%) protection from STDs, and thus for those at risk of STIs can be doubled up with another, more effective contraceptive method.