Whether youre out there having a blast meeting new partners or enjoying the partner you currently have (over and over again), theres a little something you might be trying to avoid: getting pregnant. Most of us spend forty or more years in our reproductive phase of life, so this simple act preoccupies some women for a big chunk of time. Avoiding pregnancy is a necessary part of a healthy heterosexual sex life, since making babies is exactly what our amazing reproductive systems are designed to do. There are a whole bunch of ways to block egg and sperm from ever meeting (or from implanting if they do meet). And yet the unintended pregnancy rate in the United States hovers at about 45 percent (higher than any other developed country). Guess what? This isnt because all those women arent using contraception. Its because some birth control has higher efficacy rates than others. And its because of human error; not all of us use contraception correctly—you know, like missing taking your pill. Only about 14 percent of women who do not use contraception at all were responsible for approximately 50 percent of those unintended pregnancies. The highest pregnancy rates, not surprisingly, occur among young women aged twenty to twenty-four, and those who are socio- economically disadvantaged. Accessing birth control is an issue for more than twenty million women in the United States, and data shows that certain racial/ethnic groups also have higher rates of unintended pregnancies.

There are so many different contraceptive options out there, including some super long-acting ones that prevent pregnancy more than 99 percent of the time. Theres everything from male or female sterilization (not an option if you do want to have kids one day) to implants to IUDs. These require no compliance from you—you dont have to remember to take that pill, or insert a ring, or put in a sponge. Youre always covered. So why arent more women choosing these methods? Access is an issue. Education is an issue. Insurance is an issue. Cost is an issue. And even when you have insurance, access, and cash, birth control can be a tale of compromises. Many women love what theyre using, but generally theres no one-size-fits-all. You can lament that the options suck because of, well, patriarchy, but think about it. When youre trying to thwart nature and keep your body from doing what its built to do, of course there isnt always a perfect answer. Its all about educating yourself about your options and making the right decision for you.

Some contraception feels so right, so effortless in your body, that you wont even notice it—thats the goal. But with others, you might spot, you might get headaches or mood changes or cramps. Or you might have to stop in the very middle of just the right kind of do-me-now heat and take a pause to go insert something and maybe spermicide will drip out of you. Heres the thing, even if your method is not totally perfect, its still awesome. As in: birth control is literally about controlling when you want to give birth, to bring a child into this world. Thats freedom—a freedom women have not historically enjoyed and which many women around the world still dont. Get on top of that, take charge of your reproductive health, and find the contraceptive method that works best for your unique body.

Finding your best birth control may take a moment; be patient. If you dont adore what youre currently using, take the time to research other methods and make a change. Planned Parenthood, Bedsider, Centers for Disease Control and Prevention, the World Health Organization, and many other organizations are solid resources. Some of their websites even let you take a quiz or personalize your search to determine what options will match your specific needs.  Then consult with your doctor about your research; you may read about something cool-sounding youre sure is just the thing for you, but your doc—be it your gyno, GP, pediatrician, midwife, or nurse practitioner—can advise on how your health history and your family health history may determine whats medically best. If youre trying something new and dont like it, keep changing until you find a method youre comfortable with. If something was working well with one partner and not so much with a new partner, mix things up. Just make sure to use backup methods as you make changes, in case youre uncovered as you transition from one type of birth control to another.

THE MIGHTY CONDOM

Perfect use: 98 percent

Typical use: 82 percent

Condoms are the only contraceptive available that protects our bodies from STIs. To repeat: no other method of contraception can safeguard your body from sexually transmitted diseases and infections, including HIV/AIDS. So they always have to be part of the deal.

Since the condoms most commonly used go on penises and require male participation, some women think its not their job to carry them in their purse or store them in their bedside table. Dont be that person. Be the woman carrying condoms at all times, because sex is awesome and being safe shows you give a damn about your health. Get good at rolling them on. And require them: Every. Single. Time. You. Have. Penetrative. Sex. Please and thank you.

Condoms also pair beautifully with all other birth control methods and increase contraceptive efficacy with minimal to no side effects. Sensitive to latex? No problem, try a non-latex condom. Condoms are also widely accessible, dont require a visit to your doctor, and dont cost a lot (some clinics and schools even offer them for free).

Here are a few other things to know about condoms: Latex can break down if paired with oil-based lubricants (that means mineral oils like baby oil as well as petroleum jelly). So dont use those as lubes. Also, men are not supposed to wear more than one. Double bagging sounds super protected but actually it causes friction that can lead to rips or tears in the condoms. And while condoms are great to buddy up with other birth control methods, you dont want to use a male condom with a female condom; that can also cause them to break. Other things that can weaken condoms include vaginal estrogen and oil-based antifungal creams. If youre ever in doubt, ask your doctor or your pharmacist if a cream or a lubricant is OK to use with condoms.

Abstinence

100% effective but only if you really, truly don’t have sex

Not having sex works well for not getting pregnant. But then again you wont be having vaginal sex. Which can be a bummer. If its not an issue for you to give up, go for it. There are certainly plenty of other ways to get off with committed partners and new-to-you partners alike. Keep in mind putting a penis inside you—unsheathed—for just a little bit but not for the whole time is neither abstinence nor a good idea. You could still get pregnant and you could also contract an STI.

Sterilization

Perfect use: greater than 99 percent

Typical use: greater than 99 percent*

If you are totally 100 percent sure you and your partner do not ever want to have biological kids—ever—then getting your tubes tied or your partner having a vasectomy is a highly effective and hormone-free way to prevent pregnancy. It can take a while to come to this conclusion, so sterilization tends mainly to be an option for people who have already had some kids and would prefer not to have more. Its also a good option for women for whom getting pregnant presents a big health risk. If youre interested in sterilization, do some research and make an appointment to talk through all the options and possible side effects with your doctor.

Diaphragm

Perfect use: 94 percent

Typical use: 88 percent

These are barriers, typically made from silicone, that are used with spermicide. They come in several sizes—you get fitted at an appointment with your doctor. Theres also a one-size-fits-most version that does not technically require a fitting, but does require a prescription. You might want to do a test run at your doctors office anyway, just to make sure its comfortable and you can insert and remove it without issue. For the multi-sized kind, you need to be refitted if you gain or lose a considerable amount of weight or if you have a child. They can for sure take some getting used to. You fill it with spermicide (a deal breaker if youre allergic to spermicide) and insert (with clean hands) within two hours before you know youre going to have sex. If you put it in before that two-hour window, like up to three to six hours before sex, thats OK, too, but youd need to reinsert spermicide. If you wind up having a few rounds of sex, youll also need to insert additional spermicide in your vagina (do not remove the diaphragm!), which can get things pretty lubed up. Then, after all is said and done, you leave it in place for another six hours. Next, you have to remove it (you unhook it with your finger and try not to spill the body-temperature spermicide its holding as you slide it out), wash it, and store it. You cant leave it in for more than twenty-four hours because it elevates the risk of toxic shock syndrome. If youre using lubricant with a diaphragm, it has to be water- or silicone-based. Oil-based lube can break down the silicone. Some women are sensitive to the spermicide even if theyre not fully allergic to it. It can change vaginal pH and create irritation. Diaphragms can also increase risk for urinary tract infections. Some men claim they can feel them inside their partners, but thankfully if you put it in correctly you yourself wont feel it. It can also be knocked out of place by very energetic sex. The good news is that its effective immediately after you insert it. Once you get used to the routine, using a diaphragm and knowing how to check it for leaks becomes, well, routine.

Cervical Cap

Perfect  use: noavailable

Typical use: 71 to 86 percent

Caps are quite similar to diaphragms in terms of insertion, removal, and care. Again, there are several sizes of caps and youll need to get fitted by your doctor. Some health clinics will have them in stock, but not all drugstores do, so you might need to mail order one once you have your prescription. You can have the same cap, if it doesnt have a hole, for several years. The difference between caps and diaphragms is that caps are a lot smaller and their efficacy rate stinks, especially for women who have already had children. Youre definitely going to want a backup method with a cap. Like a diaphragm, you fill it with spermicide and insert it up to six hours prior to having sex, have to reinsert more spermicide if youre going for several rounds of fun, and then leave it in for at least six hours before removing it. The spermicide can interfere with vaginal pH, which in turn can cause irritation. Caps arent a great option unless youre in a relationship where getting pregnant wouldnt be a hardship. While partners dont usually complain of being able to feel caps, it could technically get thrust out of position if things are really raucous or by a particularly large penis. Some women report an increase in UTIs when using cervical caps.

Sponge

Perfect use: 80 to 91 percent

Typical use: 76 to 88 percent

A sponge is literally a small sponge, typically made of polyurethane, which contains spermicide. You use a small amount of water, like two to three tablespoons, to activate the spermicide before insertion, then you insert it kind of like you would a tampon (with clean hands) when you know youre going to have sex. If youre out and about, youll have to remember to take one with you. One dimpled side fits over the cervix, and theres a loop on the other side to help you pull it out. Youll need to follow the exact directions on the product packaging, but usually a sponge is effective for up to twenty-four hours and can be used for more than one round of sex during that time. It has to be left in place for around six hours once youre done. You dont want to leave it in for more than thirty hours. Spermicide allergy or sensitivity are an issue with sponges, as they are for a cap or a diaphragm. The efficacy rate isnt great, but its better for women who have not had a child yet. They are sold in drugstores with no prescription, so no doctor visit is needed to use sponges.

INTRAUTERINE DEVICE (IUD) 

Its a fairly incredible thing that you can go to your doctor, have an IUD—basically a T-shaped piece of plastic either embedded with hormones or coiled in copper—inserted in your uterus, and pretty much not have to worry about pregnancy for between three to ten years, depending on which model you have. And you literally dont need to do anything: no pills to take, no patches to remember, no spermicide to put in a cap. Thats freedom. If you dont want a hormonal IUD, you can have a copper one. IUDs, like any method of birth control, have pros and cons. But they really will keep you protected— just not from STIs.

Outside the United States, the IUD is the most popular method of birth control. If youre ever feeling concerned because it just feels too convenient to be true, you can pop a (clean!) finger inside you and feel its strings for reassurance its there. They dont hang down like a tampon outside of your vagina; theyre internal. And youre never supposed to pull or tug on them. Your doctor can check them at your yearly checkup, too. (And yes you can—carefully—use tampons and even menstrual cups when you have an IUD—Planned Parenthood refers to them as next-door neighbors. One is in your uterus, the other in your vagina.) If you think you feel the actual IUD with your finger, you can always have it looked at and adjusted by your doctor. Other than that, if your body takes to it well, you wont know it is there. (And neither will your partner, especially as those strings soften over time.) There are a few medical conditions that dont work with IUDs, so thats a conversation youll have with your doctor before choosing one. Youll also want to discuss the various risks of IUDs, like uterine perforation, or what to do if it falls out. For a while IUDs were used mainly for women who already had children, but now the medical community agrees they can absolutely be used in women who have not yet had a baby. They can be expensive, depending on your insurance coverage, though the fee up front evens out over time, considering how long they last. Keep in mind that the way medical billing works these days, there will be a charge for the device and another charge for the doctor who does the insertion. Some health clinics offer services on a sliding scale, so ask questions if youre concerned about cost.

Speaking of insertion, some people say it hurts like hell when an IUD goes in your uterus. Others are less sensitive. There may be some brief cramping after insertion. Many women report spotting for up to several months between periods. If this is unbearable, or even just uncomfortable, you can always have your IUD removed. When either kind of IUD is removed, theres a rapid return of fertility—key for women who become interested in getting pregnant. When it comes time to take it out, call your doctor for advice. IUD removal is usually the kind of thing you want a medical professional to do, but there are some studies that show women can take them out on their own without an issue.

Hormonal IUD

Perfect use: greater than 99 percent

Typical use: greater than 99 percent

Heres how it works: a small amount of progesterone (well, actually a synthetic version called progestin) is released from the IUD locally in your uterus—not in your entire system, which means detectible levels of progestin in your blood is very, very low. This thins out your uterine lining and thickens cervical mucus to keep sperm from reaching there. Unlike, say, the birth control pill, it does not overtake and redo your own cycle. Many women with a hormonal IUD even ovulate and get their periods, though they get lighter over time—despite increased spotting in the early months. There are a number of hormonal IUDs on the market currently that last up to five years, though at least one brand is in the process of trying to get a seven-year FDA approval.

Copper IUD

Perfect use: greater than 99 percent

Typical use: greater than 99 percent

Copper inside your uterus prevents sperm and egg from meet- ing in several ways. Its a potent spermicide because it can literally disable sperm. And it also thickens cervical mucus, making it harder for any undisabled sperm to swim. Even if an egg and a sperm manage to meet, they arent able to implant because copper creates an inflammatory response in the uterus, creating an inhospitable environment for sperm and egg. Some— but not all—women with a copper IUD report an increase in period flow and sometimes added cramping. Still, its a highly effective option for women who would like hormone-free birth control. And it can last a decade, or even longer. You wonknow how your body reacts until you try it. Concerned about what sperm-killing copper might do in the rest of your system? Data shows the levels are far too low to harm human health.

Implant 

Perfect use: greater than 99 percent

Typical use: greater than 99 percent

Implants inserted under your skin are this effective because they take human error off the table. Once its in, its in. You personally cant forget to take it and no athletic romp is going to knock it out of place. Some people dont love the idea of a foreign object under their skin—insertion is done only after your skin is numbed, by the way. Once its in, usually on your upper arm, it releases progestin for up to four years, making this a possible method for people who cant tolerate estrogen. (Actually, the FDA has approved it for three years, research shows it works for four, maybe even five, years, and most providers say four.) Progestin thickens your cervical mucus to help block sperm from getting to an egg. In an implant, it also prevents ovulation. Not loving it or decide you do want to get pregnant after all? Get it removed (this means more numbing agent, a small cut, and its out). It has a relatively quick return to fertility. It can seem pricey, until you consider the cost over four years. Heres the downside, and keep in mind that this does not happen to all women: the implant may involve irregular bleeding for the first six months to a year. That means spotting or even heavy periods. If this is not OK with you, try another birth control method. Or roll the dice and see how you react; some women say it eventually gives them no period at all. Other less typical complaints include sore breasts and a change in sex drive.

The Patch

Perfect use: greater than 99 percent

Typical use: 91 percent

The patch is basically a sticker with hormones in it. You adhere it to your skin for three weeks, then take it off for a week if you want to get a period. If not, you use a new patch at week three to suppress your period. Just FYI, if youre looking to avoid your period, you might want a different method. There is a theoretical increased risk of blood clot related to higher exposure to estrogen over time, so some providers are only OK with using the patch for twelve weeks continuously. Overall, the patch is pretty convenient and you dont have to remember to take something daily. You do have to make sure your skin is clean when you stick on a fresh patch—no body lotion, oil, or anything creamy that could keep the patch from adhering. If you have slippery skin, the patch could fall off. If it falls off, just stick it back on (if its still sticky) or try a new patch. Tape or bandages are not advised. Some women complain the super sticky adhesive gives them a rash or the edges of the patch get a bit grimy as the weeks go by. It can be worn anywhere—butt, back, thigh, arm—but your breasts. Its advisable to choose a comfortable spot where it wont get rubbed—like dont put it where your jeans hug your waist. When you take it off, youre supposed to fold it inward so any remaining hormones on the adhesive wont get out, then throw it away. Side effects can include bleeding between periods, breast soreness, and change in sex drive. Once your body gets used to it, you may see benefits like reduced cramps, lighter periods, and clearer skin (if acne is an issue). If you weigh more than about two hundred pounds, the patch wont work as well for you—your doctor can advise on better, more effective methods. Certain side effects with the patch will be worse if youre a smoker—especially if youre older than thirty-five. Try quitting—and not just because you want to use a patch. Youre worth it!

The Pill

Perfect use: greater than 99 percent

Typical use: 91 percent

The pill is super common—tons of women are on it—but its efficacy drops considerably if youre not someone who can remember to take medication. Dr. Lauren MacAfee says by the third month of use, the typical user misses three or more pills each cycle. Then you wind up doubling or tripling up on missed pills—even if thats not what your doctor would advise—and you get nauseated and vomit because of the extra hormones. Even worse? Misuse and discontinuation of the pill result in a considerable amount of unintended pregnancies. So if youre not someone who is good at taking daily meds, look elsewhere. If you are, give it a try. There are a bunch of kinds of pills on the market, but most of them use a combo of synthetic progesterone (progestin) and estrogen to take over your natural cycle and create its own cycle with lower doses of these hormones. Progestin suppresses ovulation. Estrogen prevents those eggs from developing and getting released. The two of them together change the uterine lining as well as thicken your natural cervical mucus, which helps to block sperm from getting near an egg. There are three weeks of hormones and then a week of placebo pills when you get a period. The pill can be a total goddess send for women with cramps, heavy periods, and acne, especially as it can be taken continuously—if you dont take those placebo pills and just go straight to three more weeks of hormone pills, you wont shed any lining. But the pill can come at a cost: some women report decreased sex drive, nausea, and spotting. As with the patch, you shouldnt smoke with the pill. Yet another reason to give up smoking— or to never start. Cant take estrogen? Theres a mini pill thats progestin-only and it has no placebo pills. Its tricky, as it requires consistent use—you have to not only take a pill daily but also at the same exact time every day. There are plenty of apps or even the alarm on youphone that can help remind you to take your pill. Sign up for one or set an alarm if you need it—or do both.

The Ring

Perfect use: greater than 99 percent

Typical use: 91 percent

The ring is a flexible thing that sort of looks like a rubber bracelet. The hormones are embedded in the ring. They enter your system, preventing your ovaries from releasing eggs and thickening your cervical mucus to block sperm. You wash your hands, then put it in your vagina—really anywhere in your vagina, dont worry youre putting it in the wrong spot. And, no, it cant mistakenly get shoved into your uterus, because your cervix doesnt let stuff pass through like that. Worried a partner will feel it? It can be removed for up to three hours—but only once within twenty-four hours. Just. Do. Not. Forget. To. Put. It. Back. In. Or dont take it out for sex, up to you. Other than that, you leave it in place for three weeks and take it out one week a month to get a period. Dont want a period? Wear it continuously, changing to a new ring instead of removing it for a week. It offers the lowest systemic absorption of hormones compared to the patch and the pill, which can help with some of the negative side effects of hormonal birth control. But women wearing rings still report some of the same issues as women on other hormonal methods: bleeding in between periods, sore breasts, nausea, decreased libido. It has the same smoking issue as other hormonal birth control methods—smokers over thirty-five are at increased risk for various side effects. Now for the ring- specific details: it can accidentally be knocked fully out of you when going to the bathroom—especially if youre constipated and pushing super hard. You may not even know it fell out! So be careful. Also, some ring-wearing women report added discharge or even irritation. There are some medical conditions that may mean added risk of blood clots, as with the patch and the pill, but those can be determined by discussing with your doctor and are no reason to rule it out as a method before you have that conversation.

The Shot

Perfect use: greater than 99 percent

Typical use: 94 percent

 Do you hate getting shots? Then this method isnt for you! Dont mind? Well, then consider this: you go to your doctor or a clinic once every three months for a quick shot, and ta-da, youre covered. This is a pretty good deal for women who canremember to take the pill. But if youre not great about making follow-up appointments, then the shot may not be for you. Some clinics will get in touch with you and help remind you to come in for your shot. If youre late in making an appointment, your doctor may give you a pregnancy test before giving you another shot. The shot contains no estrogen, just synthetic progesterone, which prevents ovulation. Usually its done in your arm or your butt. If youre thinking about getting pregnant in the near future, you might want to choose another method. Return to fertility with the shot is slow. Women tend to have strong feelings about the shot—some people adore it, some cant handle it. You wont know which camp you fall in or how your body takes to it if you havent tried it. The positives are clear: its easy, its effective, you can forget about it for a few months, and, unlike other more visible methods like the patch or the implant, no one can see or feel youre on it. The negatives are: if you dont like how it makes you feel, you cant go off the shot as quickly as you can other methods; you just have to wait out the three months. Some data shows that the shot is associated with bone mineral density loss, but theres no evidence it increases incidences of fractures. When you go off the shot, research shows bone density returns to what it was. If that concerns you, talk to your doctor. Some women blame the shot for weight gain; irregular bleeding, which can last up to twelve months before evening out and giving most women a lighter period (or no period); loss of libido; depression; and nausea.

Fertility Awareness Method (FAM)

Perfect use: 95 to 99 percent

Typical use: 76 to 88 percent

This means learning the ins and outs of your own cycle— the physical signs, symptoms, and other standard datfrom months of observation—and using them to figure out when you are and are not fertile. You can read” your cervical mucus and secretions (some kinds indicate ovulation); you can use apps on your phone to help track data; you can use ovulation predictor kits; you can take and make charts of your temperature month by month; you can use a visual aid like Cycle-Beads. And you can do all these at once. Fertility awareness is not a great idea as your only form of birth control if you have irregular cycles or youre not super in touch with your body or comfortable with your cervix. Yes, you need to know where your cervix is; some women take monthly notes on the position and shape of their cervix. That involves touching it. FAM is not as woo-woo as it sounds. It has real history! And, in modern times, theres an iPhone app to be used with your thermometer—it tracks the data you take. This can truly be effective. In Sweden, one app and thermometer combo has even proved to be more effective than the pill. If youre allergic to spermicide, its spermicide-free. But you really, really have to be diligent, have to know what youre doing, and, once you do, you have to actually not have sex on your fertile days, which could be a full week—or use great backup. Your partner needs to be down for that, too. If your period is irregular, FAM is not for you. Other pros: its free, or super low cost for an app and a basal thermometer or ovulation kits, and doesnt require a trip to the doctor. Though youre gointo have to pay for a barrier method for the days you think youre fertile. You might want to keep some emergency contraception around in case you have unprotected sex on the wrong day. If youre intrigued, pick up a copy of Taking Charge of Your Fertility by Toni Weschler. And dont drop any birth control until you know what youre doing!

WHATS EMERGENCY BIRTH CONTROL AND HOW DOES IT WORK?

Emergency contraception or EC is what you can take to prevent a pregnancy after unprotected sex but before sperm meets egg. Because there is no embryo, this is not an abortion, nor is it the abortion pill. Accidents happen. Condoms can break or slip off. Someone you think is wearing a condom isnt, or took it off. Drinking or doing drugs might impair good decisions. Maybe you misread your fertility method chart. Perhaps your cervical cap got knocked out of position. And so on. Thankfully there are several methods of contraception available to prevent pregnancy from happening within a certain amount of time after unprotected sex. Depending on the type of EC you choose, it can inhibit or delay ovulation, alter sperm motility by thickening cervical mucus, or alter the uterine lining to prevent implantation. Again, these methods are not at all the same thing as the so-called abortion pill; these prevent pregnancy from ever happening in the first place. The abortion pill, on the other hand, is taken any time after a positive pregnancy test for up to ten weeks gestational age—and under the advice of your doctor.

There are several hormonal EC methods available. You can either take an over-the-counter morning after pill thats a high dose of synthetic progesterone. It will block or delay ovulation as well as thicken cervical mucus. Its well known as Plan B, widely available, not covered by insurance, and is usually around fifty dollars. Some states have rules about women under eighteen purchasing it. You need to take this within seventy-two hours of having sex and carefully follow the directions given to you by the pharmacist. Or you can call your doctor—time is of the essence, dont delay picking up your phone! There is one kind of morning-after pill that requires a prescription. Its called Ella and is highly effective, particularly for overweight women, and can be used within five days after sex. Or your gyno can walk you through taking higher than normal doses of certain birtcontrol pills. Taking extra amounts of an estrogen and progesterone combo pill as outlined by your doctor will also delay ovulation. The extra estrogen does tend to make some women nauseous. Another option your doctor may suggest is having a copper IUD inserted within five days after unprotected sex. It will do what it always does—impair any sperm that do make it to your uterus as well as create an inhospitable environment for implantation. This is also the only option that will provide ongoing pregnancy prevention going forward—win-win.

*The perfect use and typical use ratings on the following pages come from Bedsider.org

This article was excerpted and adapted from our CEO Meika Hollender’s book, Get On Top (Simon & Schuster, 2018). Buy it here!

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