What should I know before starting birth control?

Birth control (aka contraception) has come a long way in the past 50 years. There’s no “one-size-fits-all” form of contraception, but if you know what you’re looking for — and you know how to use the birth control method to get maximum efficacy — there’s likely a great fit out there for you. And the best way to make an informed decision is to know the information. Ahead, learn about the basics of birth control, side effect questions, and more.

Which methods of birth control are most effective…and why?

Some types of birth control are more effective than others — but you already knew that. The most effective forms are those that don’t require the user(s) to do or remember anything. These “long-acting” options involve a single procedure that lasts for years — a “set it and forget it” mentality. And within the world of long-acting contraceptives, there are both permanent and reversible methods:

• Permanent contraception describes tubal ligation (the surgical cutting and tying of the fallopian tubes) and vasectomy (the surgical cutting and blocking of the tubes that carry sperm from the testicles). Tubal ligation is about 99.5% effective at preventing pregnancy while vasectomies have an efficacy over 99.8%.
• Long-acting reversible contraception (LARC) includes IUDs (intrauterine devices) and implants. IUDs are small, T-shaped devices that are inserted into the cervix (the opening of the uterus) by a trained medical professional. Depending on the type, they can be left in place anywhere from three to 10 years. Both forms of IUDs (copper and hormonal) are over 99.2% effective. The implant (Nexplanon®) is a small rod that is inserted into your arm and works best during the first three years of insertion. The implant is 99.9% effective.

Among the short-acting forms of contraception, hormonal contraceptives are much more effective than non-hormonal forms because short-acting forms allow for human error. This is why efficacy rates are reported as “ideal use” and “typical use.” Typical use is always less effective than ideal use because users deviate from product directions (this isn’t always the user’s fault, as education on use can be flawed or misunderstood). However, when used correctly, short-acting hormonal forms of contraception can be very effective:

• The Depo® shot is a dose of a progesterone that is given via injection every 13 weeks. The biggest reason for reduced efficacy is a late dose. Plus, it gets more effective the longer you use it. Depo® has an efficacy rate of 99.8% with perfect use and 96% with typical use.
• Combined oral contraceptive pills (COCs) contain both synthetic forms of estrogen and progesterone. These pills should be taken around the same time every day, though there is a 24-hour window for missed doses. Of course, some people still struggle with daily medications. The effectiveness of COCs is 99.7% with perfect use and 93% with typical use.
• Progesterone-only pills (POPs) have less room for error than combined pills. The window within which someone has to take the medication can only fluctuate within a three-hour time frame from day to day. Also, because estrogen works to enhance the efficacy of pills, progesterone-only forms are simply not as great (though they’re still pretty great) at preventing pregnancy. POPs are 98% effective with perfect use and 91% with typical use.
• The patch and intravaginal ring are combined contraceptives (like the COCs) and are a little less intensive as they only require changing weekly (the patch) or every three weeks (the ring) — but there’s still room for mistakes. Also, because absorption of the hormones in patch forms can vary with increasing BMI, these forms don’t work as well as their combined pills that are sent directly to the bloodstream. Both the patch and ring have an efficacy rate of 99.7% with perfect use and 93% with typical use.

Which brings us to the last category: non-hormonal, short-acting contraceptives. These take the need for a procedure or medication out of the equation, and most of these forms are available over-the-counter. However, these contraceptives generally require an in-the-moment act (like putting on a condom or inserting a diaphragm), so if you’re overcome by passion or just don’t follow directions exactly right, there is a lot of room for human error.

• The first contraceptive you ever learned about was likely condoms. They come in a variety of textures and sizes, and they need to be used with every act of penetrative intercourse to be most effective. If you forget, or if you don’t use them appropriately, there is a chance of pregnancy. Other errors include using the wrong lube (never use oil-based with latex), opening it too aggressively, putting it on inappropriately and not holding it when pulling out. With perfect use, efficacy can be as high as 98%, but with all of this opportunity for mistakes, typical use efficacy is around 87%.
• Diaphragms are flexible discs that are inserted into the vagina before sex and are left in place for six hours after sex. They work with spermicide to form a seal and block the cervix (entrance into the uterus) while killing sperm. But there is a chance that sperm can get through, and consistency and timing matter. With perfect use, efficacy can be as high as 94%, but typical use has about 83% efficacy.
• Spermicide and contraceptive gels are placed in the vagina prior to sexual intercourse and work by killing sperm directly or by creating an acidic environment that disables sperm. They are not typically recommended for use by themselves, but they can always be added to other barrier methods like condoms or diaphragms to improve efficacy. Spermicides are 84% effective with perfect use and 79% with typical use. The main contraceptive gel on the market (Phexxi®) cites 93% efficacy with perfect use and 86% with typical use.
• Finally, natural family planning is a form of contraception that involves NO medications or devices. So what does it require? Something we like to call regular effort. This method is founded on a deep understanding of your menstrual cycle — specifically ovulation. There are many ways to identify when your fertile window is, but it can be difficult, even with the best methods, to determine exactly when you ovulate during your cycle. Furthermore, it can be normal to have variation in your cycle from month to month, leaving a lot of room for error. When done perfectly, these methods can be up to 94% effective. However, in reality, it ends up being closer to 77% effective.

Why does birth control have side effects?

Nearly all medications have side effects and birth control is no exception. The most stereotypical side effects are generally due to hormone changes. You may already experience this, but within the menstrual cycle there are times where your body experiences a natural spike in things like acne, mood swings, and libido. These are all due to temporary changes in the levels of (mainly) estrogen and progesterone.

Consider what might happen without those natural spikes. Hormonal forms of contraception deliver a continuous level of progesterone with or without estrogen. Progesterone-only forms of contraception can cause changes in bleeding pattern (often not predictable), worsened acne, headaches, and mood changes. If you’re using one of the combined forms of contraception, the side effects tend to be a bit milder because estrogen keeps some of the progesterone effects in check. However, the estrogen can cause both welcome and unwelcome side effects, including reduced menstrual bleeding and cramping, relief of mood swings that occur around a period, improved acne, breast tenderness, and increased risk of clotting.

Another type of side effect is a local reaction. For example, individuals with an allergy to latex may have irritation and inflammation of the vagina following sex. (In this case, try a different type like polyurethane!) Some people on the patch have irritation from the adhesive that keeps the patch attached for seven days. (Hot tip: Flonase® sprayed on the skin before applying the patch can help!) And while the copper IUD does not have hormonal side effects, it can cause some significant worsening of menstrual bleeding and cramps, especially in the first six months after insertion.

Can birth control affect my libido?

Unfortunately, yes. Our bodies have tons of hormones, and while most hormones have a “main” role within a specific body system, they usually have smaller purposes and interactions with other parts of the body. Estrogen and progesterone are a few of the biggest players in the menstrual cycle, but they also influence the activity of other hormones in the body. Through a couple of different mechanisms, hormonal contraceptives (which typically provide a steady dose of fake estrogen and progesterone to the body) have been shown to reduce levels of circulating testosterone. Yep, even females have testosterone, it’s just at lower levels compared to those with male anatomy. The result is that, to different degrees, libido may be impacted.

Does birth control cause depression?

The straightforward answer is no, but it’s a little complicated. If you have underlying mental health conditions like anxiety and depression, it is possible that they may worsen with contraception. This does not happen to everyone, but it’s good to be aware. On the other hand, there is no evidence to show that contraception causes depression in someone who is otherwise not susceptible.

Does birth control affect different people differently?

It’s hard to say exactly which (if any) side effects someone is going to have, but it’s important to know what to look out for before starting a medication. Most side effects usually improve within three to six months of starting a form of contraception, but if they are bothersome to you, check in with your doctor. Short bursts of medications for breakthrough bleeding, acne management, mental health optimization, and pain control can all be ways to help with side effects.

One mysterious part of hormonal contraception is weight changes. Weight gain in particular is often reported with hormonal contraception use. While research doesn’t show that this is a consistent side effect, the accounts of individual users support the risk of slight weight gain on contraception, especially with Depo®.

Can birth control affect my ability to become pregnant in the future?

Unless we’re talking about tubal ligation or vasectomy — both of which significantly impact your ability to get pregnant in the future — the answer is no. However, the relationship between the two is often confused. We are naturally more fertile when we’re younger and it becomes more difficult to conceive when we’re older. On the flip side, a younger person is more likely to use contraception to avoid pregnancy, putting the brakes on during a time in their life when fertility is at its presumed peak. When that person is ready to try having children, they may find that it’s a struggle. It may be because fertility changes as we age, or it may be that birth control was masking an underlying fertility issue. Regardless, birth control is not the cause.

There is also a distinction in the “return to fertility” timeline (or how long after stopping the contraceptive that your fertility returns to baseline). Generally speaking, the short-acting and non-hormonal forms of contraception restore ovulation quickly (meaning once you stop, fertility is almost immediately restored). Once a Nexplanon® implant or hormonal IUD is removed, it can take up to a few months for fertility to return to baseline. The method that has the longest residual impact on ability to conceive is Depo®. After the final shot, it can take up to a year for cycles to get back to normal.

What is post-birth control syndrome?

There’s a newer term for the period of adjustment that your body goes through after stopping any form of hormonal birth control. “Post-birth control syndrome” is not a medical diagnosis, but it describes some symptoms that occur as your body’s natural hormone signaling restores itself. Some of the symptoms are similar to the ones that are experienced when starting hormones: abnormal bleeding and menstrual cycle irregularities, breast tenderness, and headaches. It can also be difficult to decipher which symptoms are due to your hormone signaling and which are from withdrawal from birth control. Mood swings and acne, for example, are also often attributed to post-birth control syndrome, but it’s also important to consider if birth control was actually treating or managing these symptoms. At the end of the day, it’s difficult to say. The one thing we do know is that everyone experiences contraception differently, so it’s best to know ahead of time what all of your options are and to remember that finding the right contraception for you may be a journey.

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.