Help! How do I choose between birth controls?

For every positive birth control review, you’ll find an equally horrific personal story — but don’t let that be a reason to run in the opposite direction. Everyone has individual needs and preferences, no two bodies react the same to a single type of contraception…you know the drill. Think of finding the right birth control as a journey. It’s totally normal to experiment with multiple types of birth control before finding the right fit — just remember that what we benefit from now is not necessarily what our bodies will need as they age.

Take a deep breath and read on to learn about your options, their benefits, their contraindications, and everything in between. And while it is a valid way to avoid pregnancy, abstinence will not be discussed here. It’s totally healthy and normal to want to have sex.

Which birth control is right for me?

A quick refresh: This is going to be an individual journey, so the answer isn’t straightforward. However, there are a number things to ask yourself before you make a selection:

• Am I good at taking medications at the same time every single day? Or would I prefer a “set it and forget it” method? Or something in between?
• Would I be open to frequent shots, having something inserted into my arm, or having something inserted into my cervix?
• Am I open to using hormones?
• Do I smoke? Do I have migraines with aura, high blood pressure, abnormal liver function, or a history of stroke or breast cancer? Do I have any allergies to latex?
• Do I struggle with acne, painful cramps, PMS (premenstrual syndrome) or PMDD (premenstrual dysphoric disorder)?
• How regular is my cycle? Am I tracking it carefully? Am I willing to track it carefully?
• What’s my BMI (body mass index)?
• What’s my budget? (For what it’s worth, all of these options are cheaper than having a baby.)
• Does confidentiality or privacy matter? Will I be using someone else’s insurance?

An additional (and very important) consideration is how perfect you need your birth control to be. Some forms — usually those that don’t require you to do or remember anything — tend to be more effective than the others. But keep in mind that even those that have room for human error can still be quite effective.

What if I forget to take a pill?

When looking at options, ask yourself if taking a daily medication or using something every single time you have sex is realistic for you. There are some great options, including birth control pills and condoms, that work very well when used exactly as directed. However, the types of contraception that are most effective in reality are the ones that don’t require any effort.

If your ideal form of contraception is “set it and forget it,” consider these long-acting options:

• Nexplanon: This is a thin rod that slowly releases a synthetic progesterone into your system, providing contraception for three years. It is inserted into your arm through a minor procedure by a trained provider and has an efficacy rate of 99.9%. Because it’s a hormone, the most common side effects are with the menstrual cycle. Many people have spotting or steady bleeding in the first few months after having the rod inserted. However, this bleeding (especially if heavy) can be managed with temporary medications — just chat with your doctor. Once the rod is removed, most people return to their fertility baseline after a month or so.
• Levonorgestrel intrauterine device (IUD): This T-shaped device is inserted into the cervix (the opening of the uterus) in a procedure that requires a setup like a pap smear — get ready to get those feet in stirrups, baby! We’re going to be honest: Insertion can be a little painful, so you should definitely ask for (scratch that, demand) pain control before the procedure. There are three different doses of levonorgestrel available, each corresponding with the amount of time that the device is effective. The highest doses last for eight years, medium doses last for five years, and lower doses for three years. This also corresponds with the severity of side effects. All users generally have reduced pain and period bleeding, but those on the highest doses most commonly lose their periods for a while, though this can happen with all doses. Efficacy rates are over 99.2%.
• Copper IUD: The copper IUD is also a T-shaped device that is inserted into the cervix by a trained provider. It’s coated in copper – no hormones here – and works by creating a hostile environment for sperm and by blocking the cervix. These have an opposite effect on menstrual bleeding from the hormonal IUD, often causing heavier and more painful periods in the first six months after insertion. There are two types of copper IUD, one that lasts for three years and one that lasts for ten years. Efficacy rates are over 99.2%.
• Tubal ligation or vasectomy. These are great options if you’re totally sure you’re never gonna have kids — or if you don’t want any more! Tubal ligation (a procedure that involves cutting and tying of your fallopian tubes) is very effective at preventing pregnancy, with an efficacy rate of 99.5%. Vasectomy (a procedure that involves cutting and blocking the tubes that carry sperm from the testicles) is also super effective, with an efficacy rate of 99.9%. And while you’ve probably heard of these procedures being reversed, don’t bank on that. It’s best to consider these to be permanent forms of contraception.

Of course, all of the above require a provider and a procedure. If that’s not your vibe, read on.

Are hormones safe?

There are a lot of misconceptions about hormones and hormonal birth control, but it needs to be noted that hormonal forms of birth control are some of the most effective and safe options out there. (There are even some medical conditions that require the use of hormones to stay healthy, like type 1 diabetes and hypothyroidism.) However, hormonal birth control will naturally come with some side effects. Here’s why:

• Hormones are basically little messengers, allowing different parts of the body to communicate with one another. They also like to communicate with each other, sometimes telling another hormone to “speak up” or to “quiet down.” This is exactly how our bodies create a menstrual cycle.
• There are four main hormones that play a role in the menstrual cycle: two produced by the ovaries (estrogen and progesterone) and two produced by the brain (FSH and LH). Estrogen production increases over the first two weeks, ultimately reaching a level high enough to cause a spike in LH production. This leads to ovulation. After ovulation, progesterone is released by the ovary. If there is no implantation of a fertilized egg, progesterone levels go down and signal to your uterus that it’s time to have a period. If a pregnancy begins, progesterone production continues, halting the menstrual cycle.
• All hormonal birth control contains some form of synthetic (lab-made) progesterone. When your body detects a steady dose of (synthetic) progesterone, it thinks there is a pregnancy and blocks ovulation. Depending on the dose and formulation of progesterone in your birth control method, your uterus typically gets a little confused. Most people experience a change in their bleeding patterns while on progesterone (ranging from spotting and breakthrough bleeding to absent or inconsistent periods). Some forms of progesterone can also cause worsening acne, oily skin, and hair pattern changes.
• Synthetic estrogens were added to birth control to balance out some of the progesterone side effects. Contraceptives containing estrogen allow for better period control, which usually means reduced bleeding, improved cramps, and more regularity. They also control the negative progesterone side effects like acne and oily skin.
• Both synthetic estrogen and progesterone have the potential to reduce libido (sex drive) by reducing the amount of testosterone circulating in your body. If you’re someone who is prone to depression or anxiety, estrogen and progesterone may worsen your condition. On the other hand, for those who experience significant mood changes around the time of their period, estrogen and progesterone actually improve mood by controlling the large fluctuations that impact emotion.

Who shouldn’t take hormonal birth control?

First of all, if you don’t want to, you don’t have to. But for some people, using hormonal birth control can be dangerous. This primarily applies to estrogen-containing contraception, though progesterone has a few contraindications as well.

At baseline, taking estrogen carries a slight risk for developing blood clots and increasing your blood pressure. If you don’t have any other risk factors, your chances of developing a clot and high blood pressure are incredibly small. However, having a medical condition or habit that also increases the risk of clots or high blood pressure makes the use of estrogen-containing medication riskier. It’s generally advised to avoid them if you smoke, have migraines with aura (vision changes), high blood pressure, abnormal liver function, or if you have a history of stroke or breast cancer. Progesterone does not have the same association with blood clots, but don’t use it if you have breast cancer or known liver disease.

What are the pros and cons of birth control pills?

There are actually two main forms of birth control pills: combination (containing both estrogen and progesterone) and progesterone-only pills. The directions for use are essentially the same: Take one pill around the same time every day. Here’s the thing: Your timing has to be nearly exact for most progesterone-only pills, with only a 24 hour window to be considered on time for a combination pill. So how does someone choose between the two?

• Consider safety: You should not use an estrogen-containing medication if you smoke or if you have migraines with aura, high blood pressure, abnormal liver function, or if you have a history of stroke or breast cancer.
• Ease of access and affordability: If you have access to a prescriber (usually doctor, nurse practitioner, physician assistant, or pharmacist) you can get a prescription for a combination birth control pill. If you don’t have access, or if you want to avoid using insurance, progesterone-only pills can be purchased over the counter.
• Better period control: Progesterone pills may or may not stop your period, but they are also known to cause higher rates of spotting and irregular period bleeding. Combination pills are much better at period management. They generally result in lighter periods, improved cramps, and more regular bleeding. Plus, you can take combination pills to stop your periods completely.
• Additional side effects: Progesterone alone may worsen acne and cause hair loss.
• Mood benefits: For conditions like PMS (premenstrual syndrome) and PMDD (premenstrual dysphoric disorder), combined pills have been shown to significantly improve symptoms.
• Effectiveness: Combination pills are also slightly better at preventing pregnancy by 99.7% with perfect use (dropping to 93% with typical use), which is a bit higher than that of progesterone-only pills at 98% and 93%, respectively.

If you’re really looking for that combination pill effect but know that you are absolutely not a match for something that needs daily attention, you still have two other prescription options:

• Contraceptive patch: This is a square sticker that releases estrogen and progesterone through the skin. Each patch lasts for a week, after which you swap the old one out for a fresh one. Here’s the thing: There are a couple of issues with the patch. First, it can be irritating to the skin. (Spraying on Flonase® before applying the patch can help!) The second issue is BMI. Unfortunately, the patch has been shown to be less effective for those with a BMI over 30. When used under ideal conditions, the patch can be as high as 99.7% effective, but it drops to 93% with typical use.
• Intravaginal ring: This combination product is a ring inserted into the vagina and left in place for three weeks. Some forms are disposable while others can be washed and reused for up to a year. Make sure you know which product you have! When used correctly, it works great. The ring is 99.7% effective with perfect use and 93% effective with typical use. And most importantly, it can be used for any BMI.

What about that birth control shot?

Depo Provera® is an injectable, progesterone-only contraceptive given every 13 weeks. When administered on time, it’s up to 99.8% effective at preventing pregnancy. Average efficacy is around 96%, but that’s usually due to a late shot or lack of protection in the week following the first injection. It's a longer-term contraception option without the need for a procedure.

Now, let’s talk about some side effects. It’s the birth control most commonly associated with weight gain, so if that’s a factor in your decision making, it might not be your first choice. Additionally, it’s not ideal for someone who wants to try to have a baby soon after getting off of the medication. We’re not exaggerating: Depo® can impact fertility up to a year after the last shot. And finally, there is emerging evidence that prolonged use of Depo® is associated with the risk of a benign brain tumor. You deserve to know all of the facts before making your decision.

Are there non-hormonal birth control options?

As previously mentioned, non-hormonal birth control — with the exceptions of the copper IUD and tubal ligation — is not as effective as hormonal birth control. That doesn’t mean there aren’t options! They just require effort prior to or during sexual activity, with the added benefit of being short-lived and non-invasive.

The most classic example of non-hormonal birth control is the condom. It’s also the only form that protects against sexually-transmitted infections. (Want other STI protection? Get your HPV vaccine!) In case you missed it in sex-ed: The condom is a penis covering that traps ejaculate (you might know it as cum, jizz, nut, splooge…you get the point) during sex. There’s tons of textures, colors, and sizes — but all that really matters is that they fit the penis appropriately and are used every single time you have sex. This will get you up to 98% efficacy! Unfortunately, not everyone knows how to put on a condom, and many mistakes are associated with condom use, which leads to an actual efficacy rate of 87%. (Doctor-approved tip: Open the condom along the tear line gently, pinch the tip and roll it down, and hold the base of the condom when removing the penis from the vagina.)

Then there’s the diaphragm. This is a flexible, prescription-only disc you insert into the vagina before sex. How does it work? By covering the cervix — aka the entrance to the uterus — and blocking sperm. Despite how hardcore this sounds, you should not be able to feel it when it’s correctly inserted! To be most effective, it needs to be used with spermicide or contraceptive gels and be left in place for six hours after sex to allow the spermicide or contraceptive gel to do their work. Depending on the type of spermicide or contraceptive gel you use, diaphragm efficacy can be as high as 93%. However, with typical use, the efficacy drops to 84%. Spermicide and contraceptive gels can be used alone, but they aren’t as effective as when paired with another form of contraception. Both are inserted into the vagina prior to sex, working to keep the vagina at an acidic pH to kill or immobilize sperm and block the cervical entrance. (And we’re back to being hardcore!) Spermicide is available over the counter and is 84% effective with perfect use and 79% with typical use). Contraceptive gels are more effective, but currently only available with a prescription only. Reported efficacy is 93% with perfect use, 86% with typical use.

How do I do natural family planning? When during my cycle am I at highest risk of pregnancy?

For those who are very tuned in to their menstrual cycle, natural family planning can be a fairly effective option. It takes a while to build a foundation and involves ongoing monitoring, but it doesn’t necessarily need any additional medications or procedures. You’ll have to track your periods for months prior to starting, and it will require some method to determine when in your cycle you are most likely ovulating. There are many ways to do this, including basal body temperature readings, cervical mucus checks, and calendar tracking. Once you have a reliable pattern identified, you’re ready to start.

Why ovulation? Ovulation is the point in your cycle during which time an egg is released from an ovary. The fertile window — which spans from five days before to 24 hours after ovulation — is the only time in one cycle that someone can get pregnant. The theory is that if you’re using natural family planning and know when you ovulate, you can use this information to either avoid penetrative sex or use a backup method during your fertile window. If someone has a very predictable cycle and they practice this method diligently, they can reach 94% efficacy. That being said, it can be incredibly difficult to determine when you’re ovulating. Plus, you’re at peak fertility when you’re younger, so a mistake in calculations can have bigger consequences. It also doesn’t help that you’re generally hornier around the time of ovulation…

How do I keep birth control private, and how much will it cost me?

If you’re hoping to keep your decisions private, there are many over-the-counter contraception options to choose from. You can even combine them to get improved pregnancy protection! Here’s a rundown of the average price for contraceptives available at your local drugstore:

• Condom: Small packs (containing 3-12) generally cost between $5 and $15
• Spermicide: Kits can cost around $8 to $15, depending on the form and number of doses per kit
• OPill®: a 1-month supply costs about $20, but you can save money if you buy multiple packs at a time through their website

Another way to keep your contraception private is to avoid insurance. Here’s a rough estimate of what prescription contraceptives cost without insurance:

• Combination birth control pills: Generic forms can be as low as $7 per month, but brand names can cost as much as $200 per month
• Patch: Anywhere between $30 and $150 per month (Three patches that are changed weekly)
• Ring: Disposable rings cost between $100 and $200 per month; reusable ring can cost up to $2,000, but can be used for a whole year
• Diaphragm: Can be between $80 and $150 for one diaphragm that lasts up to two years
• Depo Provera®: Anywhere between $50 to $200 per shot, depending on the clinic
• Nexplanon®: The device itself costs around $1,000 and lasts for three years, but there will likely be additional insertion and removal charges by the clinic or provider
• Levonorgestrel IUDs®: Most forms are at least $1,000 in addition to insertion and removal charges
• Copper IUDs: These might be a little cheaper depending on the clinic, costing anywhere from $700 to $2000, including insertion charges

If this is sounding a bit pricey, rest assured that there are many coupon sources for contraception that can further reduce these prices. Also, ask for a generic form — they’re cheaper but work just as well!

Still not sure what birth control is right for you? Chat with your doctor. Providers who specialize in family medicine, pediatrics, internal medicine, and emergency medicine can always counsel on and prescribe contraception if you don’t have an OB/GYN.

While we love to share useful and helpful information, the above shouldn’t replace the advice of your healthcare professional. For questions about contraception and other reproductive health issues, please talk to your doctor.