Personalizing birth control to minimize health risks

UTSW
By Mahdi Awwad, M.D., 
Family and Community Medicine

Approximately 87% of women in the U.S. will use contraception during their lifetime. But when it comes to birth control, there is no one-size-fits-all method.

Condoms, IUDs, and oral contraceptives – better known as “the pill” – all have benefits and some minor risks. That’s why we help our patients take a personalized approach to finding the safest and most effective contraceptives.

For example, oral contraceptives that contain the hormones estrogen and progestin can increase the risk of stroke in some patients with certain underlying conditions. Even women who are young, active, and otherwise healthy could be at risk.

To help determine the best birth control option for you, your doctor will consider your health and family history – along with your personal preferences – before suggesting a hormonal or non-hormonal method.

Prior to prescribing contraceptives, doctors at UT Southwestern will screen you for other stroke risk factors. This screening will help your doctor determine if contraceptives containing estrogen, progestin, or both – or neither! – might be the safest, most effective choice for you.

Hormonal contraceptives: Risks and benefits

Estrogen-containing birth control

Estrogen and progestin are commonly combined in birth control pills and work by preventing ovulation, or the release of eggs from the ovaries. They also thicken the lining of the uterus and change the mucus at the cervix to prevent pregnancy. When used correctly, the pill is 93% effective against pregnancy.

Researchers have found that ethinylestradiol, a type of estrogen found in most birth control pills, increases the risk of blood clots – which can lead to stroke – by changing how the liver synthesizes certain proteins that affect clot formation.

In the 1970s, some birth control pills contained high doses of estrogen, but those formulations are no longer used. Modern, low-dose pills that include a combination of progestin and estrogen are not considered a significant stroke risk.

However, oral contraceptives like the pill can cause side effects such as nausea, weight gain or loss, acne, and bleeding or spotting between periods. Stroke risk may be higher in patients with certain underlying conditions, including:

• Migraine with aura or other neurological conditions
• History of blood clots
• Lupus and other autoimmune diseases
• Family history of stroke
• High blood pressure
• Preeclampsia (high blood pressure in pregnancy)
• Smoking, especially after age 35

Both estrogen and progestin can be found in birth control patches and vaginal ring options such as NuvaRing or Annovera. While clots caused by vaginal rings are rare, patients using the birth control patch are slightly more likely to develop blood clots in the legs or lungs. The patch and the ring are approximately 93% effective against pregnancy.

Method	Effectiveness	Pros	Cons
Pill	93%	Regular, less painful periods	Must be taken daily. Side effects can include nausea, weight gain. Slight risk of blood clots
Vaginal ring	93%	One ring lasts a month; may ease PMS symptoms	Doesn’t protect against STIs; some side effects include breast tenderness, headaches
Patch	93%	Each patch lasts a week; stays on in shower	May raise blood pressure, cause headaches
IUD	99%	Lasts 3-5 years; can make periods lighter	Doesn’t protect against STIs; side effects include mood swings, skin problems, breast tenderness
Injection	96%	Lasts 8-13 weeks; not affected by other medicines	Can take up to a year for your fertility to return to normal after the injection wears off
Implant	99%	Lasts 3 years; implant can be taken out and fertility returns quickly	May experience bruising, tenderness, or swelling around the implant

Progestin-containing birth control

Progestin influences clotting to a lesser extent than estrogen. If you are at risk of blood clots or want to avoid estrogen options, your doctor might recommend a progestin-only birth control option such as:

• The mini-pill – 93% effective against pregnancy
• Kyleena, Mirena, Liletta, or Skyla intrauterine device (IUD) – over 99% effective against pregnancy
• Depo-Provera injection (the shot) – 96% effective against pregnancy
• Nexplanon, a 4cm rod implanted in the upper arm – over 99% effective against pregnancy

Common side effects of progestin-containing contraceptives include weight gain, tender breasts, and bleeding between periods. These options are unlikely to raise stroke risk, even in women who suffer from migraines with auras, but they may not be suitable if you’ve had a stroke or have heart disease.

Non-hormonal birth control options: Risks and benefits

Barrier-method birth control – male and female condoms, diaphragms, sponges, or cervical caps that contain spermicide – prevent sperm from passing through the cervix to fertilize an egg.

Condoms

A popular non-hormonal option available without a prescription, condoms also help reduce the risk of infection from sexually transmitted infections (STIs). Available in male and female styles, condoms create a physical barrier to prevent fertilization of the egg.

• Benefits: Condoms are available without a prescription and offer protection against STIs.
• Risks: Condoms must be used correctly each time to avoid leaking or breaking.
• Effectiveness: When used correctly, male condoms are 87% effective against pregnancy and female condoms are 89% effective (effectiveness increases with proper use).

Diaphragm

A diaphragm is a shallow silicone cup that is inserted into the vagina and covers the cervix. Adding spermicide to the diaphragm makes it more effective because it contains chemicals to stop sperm from moving so they can’t reach the egg. Most diaphragms require a visit to your doctor to determine the size you need.

• Benefits: Diaphragms are convenient and reusable.
• Risks: Some patients experience vaginal irritation or urinary tract infections. Diaphragms should not be removed until eight hours after sex. Each time you have sex, you will need to reapply spermicide. Diaphragms do not provide STI protection.
• Effectiveness: When used correctly, diaphragms are 83% effective against pregnancy.

Method	Effectiveness	Pros	Cons
Condoms (male & female)	87%, 89%	Available without prescription; protect against STIs	One-time use only, can split or break
Diaphragm/cervical cap	83%	Reusable and convenient	Doesn’t protect against STIs, may cause vaginal irritation or UTIs
Copper IUD	99%	Lasts 3-12 years	May cause heavy or irregular periods the first few months
Sponge	73-86%	Available over the counter; spermicide lasts 24 hours	May cause vaginal irritation or infection; not as effective as other methods
Vasectomy	99%	Doesn’t affect hormone levels or sex drive	The surgery can’t be easily reversed
Tubal ligation	99%	Doesn’t affect hormone levels or sex drive	Considered permanent. Surgery carries small infection risk.

Birth control sponge

Contraceptive sponges are soft, round devices filled with spermicide. When inserted into the vagina, the sponge kills or traps sperm that approach the cervix.

• Benefits: Sponges are available over the counter, and the spermicide can last for 24 hours.
• Risks: Some patients experience vaginal irritation or infections. Sponges do not protect against STIs and should not be removed until six hours after sex.
• Effectiveness: Sponges are approximately 73% effective against pregnancy for women who have given birth and about 86% effective for women who have never given birth.

ParaGard copper IUD

ParaGard, a copper intrauterine device (IUD), is a non-hormonal option that greatly reduces the chance of pregnancy while also limiting side effects, including weight gain. Instead of releasing hormones, when placed in the uterus the IUD releases copper, which is toxic to sperm. An IUD is only available from your doctor.

• Benefits: Copper IUDs do not use hormones, and they can last three to 12 years. This IUD can be used as a form of emergency contraception.
• Risks: Patients may experience heavy or irregular periods with breakthrough bleeding, particularly in the first few months after getting an IUD. Rarely, the body may expel the device. IUDs do not protect against STIs.
• Effectiveness: Copper IUDs are more than 99% effective against pregnancy.

Other non-hormonal options

Other non-hormonal options include tubal ligation, also known as “getting your tubes tied,” and vasectomy. These are options for both women and men. Surgical sterilization procedures are over 99% effective and generally considered permanent. Some sterilization procedures can be reversed by fellowship-trained surgeons.

Personalized contraception planning

It’s understandable to have concerns about contraceptives, especially when looking at a list of potential side effects or considering your stroke risk factors. However, there’s an option for you, and your doctor can help you find it while also minimizing your risks. That option will be personalized to your needs, wants, and lifestyle and will help you accomplish your contraception goals.

If and when you’re ready to start a family, we’ll be at your side to customize a care plan that works best for you.

To talk with a birth control expert, call 214-645-8300 or request an appointment online.