How does a diaphragm work?

A diaphragm is a rubber dome that fits in the vagina and covers the cervix. It is both a physical and chemical barrier method. A woman who wishes to use a diaphragm as her method of birth control needs to visit a doctor to be fitted for the correct size and to receive a prescription for the diaphragm.

Diaphragms must be inserted prior to intercourse and then left in place for at least 6 hours after intercourse. Their effectiveness is dependent on the woman also using a spermicidal jelly at the same time as the diaphragm. Only water-based lubricants should be used with the diaphragm because oil-based lubricants can cause deterioration of the rubber.

There is an increased risk for bladder infections with the use of a diaphragm. Further, typical failure rates hover around 16%. In my experience as a gynecologist, teenagers don't use this method very much.

Are cervical caps similar to diaphragms?

A cervical cap is pretty much just a smaller version of the diaphragm. It does have some important differences, however. First, it's smaller than a diaphragm and tightly covers the cervix and, second, it can be left in place for up to 36 hours.

A visit to the doctor is required to be fitted for the cervical cap. As with the diaphragm, it needs to be left in place for 6 hours after intercourse, but it should not be used during the woman's menstrual cycle.

There have been problems with cervical caps collecting secretions, causing inflammation of the cervix, and producing a highly unpleasant-smelling discharge. Also, its failure rate hovers around 16%. Cervical caps are not commonly used by women as a form of birth control, and my experience is that this particularly holds true for teenagers.

What is a contraceptive sponge?

A contraceptive sponge consists of polyurethane material that is saturated with a spermicide. It's considered both a physical and a chemical barrier method of birth control. A contraceptive sponge must be soaked in running water before it is inserted in the vagina, and then it needs to be left in place for 6 hours after intercourse.

There is an increased risk of yeast infections and bladder infections with the sponge, and If a woman leaves one in her vagina too long, there may be an increased risk of Toxic Shock Syndrome.

The sponge was very popular when it was first released in 1983, but then it was taken off the market in 1994 when it was learned that the water supply in the plant where the sponge was manufactured had become contaminated with bacteria. The sponge itself was never deemed unsafe. In 2005, it was reapproved for use by the FDA, and it's now readily available in drug stores.

That doesn't mean that contraceptive sponges are perfect, however. There is an increased risk of yeast infections and bladder infections with the sponge, and if a woman leaves one in her vagina too long, there may be an increased risk of Toxic Shock Syndrome. Also, the failure rates for the sponge are around 15%, and they don't provide STD protection.

When the sponge was initially released, I would periodically see patients to assist them in removing a sponge that had gotten wedged high up in their vaginas and they couldn't remove it by themselves.

What does my daughter need to know about birth control pills?

Hormonal contraceptive methods typically involve what we all refer to as birth control pills. One of their main mechanisms of preventing pregnancy is to prevent ovulation in the first place. Simply put, if there's no egg, it can't be fertilized. And if there's no fertilized egg, there's no baby.

Birth control pills also cause a woman's cervical mucus to thicken. That means that the man's sperm is less likely to be able to travel all the way to the woman's uterus. In addition, birth control pills cause the lining of a woman's uterus to become thinner. This makes it much more difficult for a fertilized egg to become firmly attached to the side of the uterus.

All of these mechanisms combined make the pill a very effective form of birth control. When used correctly the failure rate is 1%. However, typical use failure rates are around 5%—8%. Failures are usually the result of the woman forgetting to take the pills at the appropriate intervals. That's why, as double insurance, condoms should be used in addition to the pill. (And, as we discussed above, condoms should be used every time anyway as a means of decreasing the chances of contracting an STD.)

For the vast majority of healthy young women, the pill is perfectly safe. The main risk it poses stems from the effect of the estrogen in the pill, which can increase the risk of blood clots in the legs or pelvis. However, this increased risk is actually still lower than that typically experienced by women when they're pregnant.

This risk assessment isn't intended to minimize the effect of blood clots. On the contrary, they can be quite dangerous if they travel to the lungs, heart, or brain. Therefore, any woman who has an increased risk of blood clots should not take birth control pills. This particularly holds true for women who smoke. Research conclusively proves that they have a higher rate of blood clots, and this risk increases with age.

The most common birth control pill in use today is a combination pill that contains both estrogen and progesterone hormones.

Any teenager or young adult I see who is on the pill and yet who still smokes has to listen to my friendly lecture on the hazards of tobacco. Needless to say, I strongly encourage these patients to stop smoking as soon as possible, and I offer them medical advice on how best to do so. Many young women defend their habit by telling me that they only smoke in social situations. However, it has been my observation that as I continue to see these patients over the years, the number of cigarettes they use increases—often substantially—over time. As I point out to them, quitting is much easier when you are only smoking a few cigarettes a day. The longer you wait to quit, the harder it is to quit.

In addition to smokers, women with uncontrolled high blood pressure also should avoid birth control pills. Further, those who take them should realize that they face a small increased risk of gallbladder and liver problems.

The most common birth control pill in use today is a combination pill that contains both estrogen and progesterone^[1] hormones. When birth control pills were first formulated decades ago, they typically contained high doses of estrogen. As a result, clotting problems were not uncommon. Over time, the estrogen dose in the pill has been lowered to safer levels.

The typical low-dose pill contains 30-35 ug of estrogen hormone, while the ultra-low-dose pill contains only 20-25 ug. The ultra-low-dose pill was originally intended for women in their forties, for women with high blood pressure that was well controlled, and for smokers. Now, however, the ultra-low-dose pill is the standard "first start" pill for young, healthy, non-smoking women, too.

Although the estrogen dose is lower, these ultra-low-dose pills have the same effectiveness as the standard low-dose pills, and importantly, they often have fewer side effects. When I start my patients on ultra-low-dose pills I mention that "breakthrough bleeding" (that is, bleeding that occurs in between menstrual cycles), may occur with more frequency. I tell them to call me if this is a persistent problem.

When birth control pills were first developed, scientists thought they had to mimic the normal menstrual cycle. Therefore, the pill packs contained 21 days of hormone pills and 7 days of placebo^[2] pills for a total of 28 pills. Patients were told that a pill needed to be taken each day and that their menstrual cycle would occur sometime during the placebo week. However, over time it became apparent that women didn't need to have a period once a month while taking the birth control pill. In fact, for many women a monthly period was nothing more than a nuisance and was accompanied by annoying symptoms such as cramping and headaches that could keep them from going to work or school. Thus was born the "continuous dosing" or "extended use" pill.

With the continuous dosing method, there are 91 pills per pack. The first 84 pills contain hormones and the last seven don't. A woman who follows this regimen has a period every 3 months during the placebo week of pills.

The purpose of including these seven placebo pills in the pack, rather than simply telling the woman to discontinue taking a pill for 7 days, is because it's important for women to establish a routine of taking the hormone pills each and every day so that they don't forget to do so. Further, it removes any doubt about when the woman is supposed to resume taking the hormones.

During a month that pills are taken late or are missed in their entirety, it's particularly prudent to use a backup birth control method such as condoms to ensure that pregnancy doesn't occur.

It's very important for the woman to ensure that there isn't any break between the end of using one pill pack and the beginning of using the next one. The failure to resume taking the hormone pills after 7 days of taking the placebo pills means that ovulation can occur. And that means the woman can become pregnant.

If a woman does forget to take a hormone pill, she should resume taking them immediately. Moreover, if need be, she should "double up" on the birth control pills the next day. During a month that pills are taken late or are missed in their entirety, it's particularly prudent to use a backup birth control method such as condoms to ensure that pregnancy doesn't occur.

There are some variations to the birth control regimen. For instance, some women opt to have periods even less frequently than once every 3 months. They can do so by continuously taking the hormone pills. However, it's important to note that there can be a significant initial incidence of breakthrough bleeding during the first 3 to 6 months.

Also, instead of placing pills in the pack that are strictly placebos, many manufacturers have begun adding low levels of hormones to the placebo-week pills. This step is designed to still permit a woman's monthly cycle to occur, but to reduce its related symptoms such as menstrual headaches.

Over the years I have come to the realization that there is no single type of birth control pill that is perfect for everybody. Some women like having a monthly cycle because it seems more natural and it reassures them that they're not pregnant. Other women see no point of putting up with the hassles of periods at all. Some women say that certain types of birth control pills make them moody. There are other pills that cause some women to experience skin outbreaks, and so on.

Because of these differences, your daughter should work closely with her doctor to determine which birth control pill is best for her. Further, your daughter should realize that the pill she is started on might not be the one that she eventually chooses for the long-term. Instead of stopping mid-cycle whenever they're taking a form of the pill that they decide they don't like, patients can call their doctor and switch to another type of pill without losing the contraceptive benefits of the hormones.

There's no doubt that the listed side effects of birth control pills are numerous. However, you and your daughter should know that the majority of females find these side effects to be minor in nature, and many of these side effects disappear after the first month.

Nevertheless, many women do initially experience some nausea and breast tenderness when they first begin using birth control pills. Although these symptoms should subside, if your daughter has persistent nausea, she should try taking the pill just before she goes to bed at night.

The birth control pill decreases a female's risk of uterine and ovarian cancer.

A disease that is characterized by abnormal implants of cells in the female pelvis that cause pain, adhesions, and infertility. Endometriosis can run in families and usually requires surgery to diagnose. It is often treated with the birth control pill but sometimes needs stronger medications or surgical treatment.

You and your daughter also should know that the benefits connected to taking the pill are numerous. For instance, the birth control pill decreases a female's risk of uterine and ovarian cancer. Moreover, even for those women with a family history of breast cancer but no other risk factors, most experts agree the pill does not increase their breast cancer risk.

Other benefits of the pill include a decrease in ovarian cysts and pelvic infections, a decrease in bone loss, less fibrocystic breast disease^[3], an improvement of symptoms related to polycystic ovarian disease, less anemia (due to the fact that most women on the pill notice a lightening and shortening of their cycle), a decrease in the risk of infections spreading from the vagina up to the uterus and pelvis (because the hormones in the pill cause the cervical mucus to thicken), an improvement in pelvic pain due to endometriosis^[4] and ovulation, and less acne. I also use the pill for females who complain of moodiness or premenstrual syndrome, and I usually see an improvement.

There is one quirk to birth control pills that you should be aware of. Specifically, a small percentage of women who discontinue using the pill may experience a delay of up to three months in ovulating. However, other women who discontinue using the pill may immediately become extremely fertile. This can be caused by the fact that when you take away the suppression effect of the pill, there can be a spike in the ovulation hormone, and therefore an egg can be released right away. In other words, you have the classic boomerang effect.

Another form of the birth control pill is the progestin-only pill, also formerly known as "POPs" or the "mini-pill." As the name indicates, this type of pill only contains the progesterone component and not any estrogen. This is a pill for women who cannot tolerate the side effects of estrogen, who may have hypertension, who have a history of blood clots, who smoke, or who are breastfeeding.

There are 28 hormone pills and no hormone-free pills in this type of pill pack. Progestin-only pills will not regulate cycles like the combination pill, and they work through the progesterone effect on the woman's cervical mucus and uterine lining. It is important for a patient to take these pills at the same time every day. If a woman is more than 3 hours late in doing so, then a backup method of birth control, such as a condom, needs to be used for at least 48 hours. However, if used correctly, the progestin-only pills have almost the same effectiveness as combination pills.

• [1] Progesterone is produced by the ovaries following ovulation and is responsible for preparing the lining of the uterus for pregnancy. When progesterone levels decline, menstruation occurs. Some of the side effects of progesterone include moodiness, headaches, acne, bloating, and depression. Synthetic forms of progesterone are found in hormonal methods of birth control.
• [2] A substance that contains no medicine. "Sugar pills" found in packs of birth control pills are placebo pills.
• [3] A very common, benign disorder that arises before a menstrual cycle and encompasses a variety of symptoms such as breast tenderness, lumpiness, and discomfort.
• [4] A disease that is characterized by abnormal implants of cells in the female pelvis that cause pain, adhesions, and infertility. Endometriosis can run in families and usually requires surgery to diagnose. It is often treated with the birth control pill but sometimes needs stronger medications or surgical treatment.