The purpose of contraception is to enable women to limit the risk of unwanted pregnancy. Many contraceptive methods are available: hormonal or non-hormonal, reversible or permanent, which can be used in different ways to best meet the needs of each couple.

Contraceptive effectiveness varies according to the type of contraceptive used, but also according to how it is used in “an ideal world” or “real life”.

Before prescribing contraception, your doctor will ask you several questions and discuss the most suitable method with you, depending on your choices, any possible adverse effects and potential non-contraceptive benefits expected (suppression of painful or heavy periods, treatment of acne, etc.).

Despite a vast choice, there are no ideal contraceptives, since each method has both advantages and disadvantages…

Hormonal contraception

Combined oestro-progestin contraceptives

These include two types of molecules: an oestrogen and a progestin of the 2nd, 3rd or another generation. The hormonal balance of the combination depends on the generation of the progestogen and the dose of the two molecules, which will be either more oestrogenic or more progestinic. The different conditions and side effects are directly related to this balance.

They are available in pill, patch or vaginal ring form, with the last two options allowing better compliance, though with the same constraints as the oral method.

Their contraceptive effect works in several ways: blocking the development of follicles and ovulation, modifying the cervical mucus, making the uterine mucosa unfit for implantation, etc.

They must be taken at least 21 days out of 28, but can also be taken continuously, which usually suppresses menstruation.

This is the first choice of contraceptive method for young women with no risk factors.

Theoretical effectiveness is very good: 99.7%, but is estimated at 92% in reality (linked to the risks of forgetting to take it, vomiting after taking it or problems with digestive absorption).

Delivered on prescription, some contraceptives are fully reimbursed by your National Health Insurance and private insurance company.

 

Minor side effects are problems with your cycles, breast pain, mood disorders, etc.

The major, but much rarer, effects are mainly vascular and metabolic.

An increased risk of venous thrombosis and pulmonary embolism (clots in the veins) exists with all combined pills but is greater with the 3rd and other generations. It is therefore recommended that a 2nd generation oestro-progestin contraceptive be used for initial treatment.

These risks are especially present for women with a family history of venous thrombosis, and for those with a genetic abnormality that makes them prone to thrombosis. There is an increased risk of stroke and myocardial infarction (clots in the arteries), especially in women presenting risk factors such as smoking, being overweight, diabetes, hypercholesterolemia, high blood pressure, migraines or family history. This risk becomes even greater over the age of 35.

The main reasons for not using this method are hormone-dependent cancers (breast, uterus), vascular and metabolic risk factors, certain liver and gallbladder conditions, and some diseases like lupus.

Microprogestin contraceptives

These are unique in that they contain only a low dose of progestin.

They mainly act locally by modifying the mucus, preventing implantation, but do not necessarily block ovulation, which is why they must be taken continuously, apart from those containing drospirenone, for which a 4-day break is possible.

These low doses of progestins can be used in several forms: oral, subcutaneous (implant placed for 3 years) or intrauterine (intrauterine device placed for 3 or 6 years depending on the dosage of the progestin hormone contained in the IUD).

The implant and hormonal IUD are LARCs (long-acting reversible contraceptives) whose main advantage is that their contraceptive effectiveness is excellent, around 99.9%, and above all identical in theory and practice.

The hormonal intrauterine device is most suitable for painful periods, heavy bleeding at the time of menstruation and in the case of adenomyosis. The precautions for use, complications or adverse effects are the same as for microprogestins and copper IUDs.

Unlike combined contraceptives, they are not associated with increased metabolic or vascular risk and are therefore one of the first choices for women with such conditions, but also for those in the immediate postpartum period or who are breastfeeding.

The side effects of these pills are mainly cycle disorders (spotting or absence of periods), acne, breast pain and functional ovarian cysts.

They are not recommended in cases of hormone-dependent cancer.

MPA contraceptive injection

This is an injection of MPA (Medroxyprogesterone acetate) to be given every 3 months. It is 97% effective but does not protect against sexually transmitted diseases (STDs).

The use of this type of contraception is linked to an increased risk of thrombosis.

Mechanical contraception

The copper intrauterine device (IUD)

Its contraceptive mode of action is linked to both an inflammatory reaction in the endometrium due to the presence of copper, and a probable direct toxicity on sperm.

There are different models of copper IUD adapted to the different anatomical conditions of women (size of the uterus). It may be prescribed for women who have not had a child under certain conditions (verification and information on the risks of genital infection, use of a small IUD). Its insertion is recommended during the menstrual period or just after. It can be removed at any time during the cycle. The usual duration is 3 or 5 years.

65% of the cost is reimbursed by Social Security.

The main reasons not to choose this method are an ongoing wanted pregnancy, a current upper genital infection, a malformation of the uterus, unexplained vaginal bleeding, taking certain treatments that affect immunity or allergies to copper.

Side effects include increased menstrual flow and pelvic pain.

Serious complications such as expulsion, perforation and genital infection are rare.

Barrier methods

These include the male or female condom, spermicides, the diaphragm and the cervical cap, which are much less effective than other contraceptive methods.

These are non-hormonal vaginal contraceptives that prevent the sperm from meeting the egg.

Condoms are the only method of preventing STDs and are often used in conjunction with another contraceptive method.

The use of the diaphragm and cap requires practice and the use of a dose of spermicide for every new sexual encounter.

Permanent contraception

For both men and women, this procedure is regulated by law: the patient must be of legal age and wait four months between first and second consultations.

Female sterilisation

Female sterilisation requires laparoscopy to place a clip or ring, or perform a tubal ligation. This technique avoids the use of hormones. It is a once in a lifetime procedure.

Male sterilisation

Male sterilisation consists of blocking the passage of sperm by ligating and cutting the vas deferens (vasectomy).

It is not immediately effective after the operation (90 days after the procedure). It does not protect against STDs and can be performed only once in a lifetime.

Along with the condom, it is the only effective male contraception to date. Numerous research projects are underway to develop a reversible male contraceptive that will not interfere with the functioning of male hormones.

Emergency contraception

Using it in the hours following unprotected intercourse can prevent an unwanted pregnancy and avoid the need for a Voluntary Interruption of Pregnancy (VTP or abortion).

There are several possibilities, depending on how much time has passed since unprotected intercourse:

Using high doses of Levonorgestrel (morning-after pill)

To be taken as a single dose up to 72 hours after unprotected sex. It is available free of charge to minors. There are no restrictions on the use of this method.

Administration of Ulipristal acetate (30 mg)

This can be used as a single dose up to 120 hours after unprotected or poorly protected sex. It requires a doctor’s prescription.

A copper IUD

can also be inserted within 5 days of unprotected intercourse.


Co-authored and scientifically validated by Dr Lorraine Maitrot-Mantelet,

Gynaecologist in the Department of Obstetrics and Gynaecology II and Reproductive Medicine at the Hôpital Cochin, Paris.


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