Sunday, September 29, 2013

Ode to Contraception



Warning:  As the title suggests, this blog entry is full of traditionally private personal information about menstruation and contraception.  Contraception clearly is about pregnancy prevention, but I think it is just as much about menstrual cycle regulation.  Balancing those needs is exceptionally important and, as an individual who has tried many different contraception methods, I have some insight to share about it.

I started menstruating in middle school, a little more than 20 years ago, so I have had plenty of experience dealing with the radical hormonal changes caused by the menstrual cycle.  I dealt with emotional highs and lows, uncontrolled and spontaneous crying, shooting pains in my breasts, and frequent lower back and abdomen pain.

I had a high school friend whose menstrual cycle was so regular that she predicted not just the day but the 15 minute window in which her bleeding would begin each month.  My cycle was nowhere as predictable, so I continuously worried that I would start my period during class or during work and everyone would know.  (You know, standard period fears.)  My cycles were also incredibly erratic in length.  I had menstrual bleeding as brief as 3 days and as long as 21 days.  Menstrual bleeding for three weeks straight is alarming; having relief for just 7 days to be followed by 20 more days of bleeding is a ridiculously terrible experience and made the standard derogatory line of “it must be her time of the month!” even more irritating.

My overwhelming desire to control my body drove me to oral contraception.  I had heard about “the pill” -- a near mystery in my high school girl circle -- that would make my menstrual cycle regular.  I started taking ortho tri-cyclen birth control pills freshman year of college and I rejoiced at the changes.  Adding more hormones to my body meant I suddenly had a regular cycle – 21 days of freedom followed by 7 days of bleeding – and Washington University’s Student Health Services provided the medication for free.  The pill was such an incredible gift and it was my first foray into the wide world of contraception.

However, the extra hormones also made me more emotional, so I had more extreme highs and lows.  It also delivered a new set of problems.  The pill had to be taken at the same time each day and, with my varied daily schedule, I did not have a standard routine for always taking it.  I started setting an alarm for 5:30 a.m. – a time I was generally always home -- so that I could take my daily pill.  (My roommates were less than thrilled by my early morning alarm, to say the least.)  And I had to ensure that I always had the next set of pills for the new month, which is a standard adult problem but not one that I had faced much in my late teens.

The pill was my contraceptive method of choice until I actually needed to use it for preventative birth control.  As the literature states, “less than 1 out of 100 women will get pregnant if they always take the pill as directed and about 9 out of 100 women will get pregnant if they don’t always take the pill as directed.”  I can do the math.  If we’re talking even 0.5% likelihood to get pregnant, with 50 million women, that’s suddenly 2.5 million pregnancies -- even though those women were using contraception!  (The number jumps to 4.5 million pregnancies with the 9 out of 100 number.)  Yowsa. 

I had no desire for an unplanned pregnancy and my boyfriend was anti-abortion, so I added the most effective (if used correctly) birth control method: abstinence.  When that boyfriend became my spouse, abstinence was an even less appealing option.  We added condoms as another layer of protection (although they are not incredibly reliable) and decided that we would become parents if a pregnancy resulted despite all these precautions. 

Time passed.  Eventually Eric and I became parents and we used the combined breast-feeding / low dose pill / condom method to prevent another pregnancy.  Once we were certain we had the right number of kids, Eric had a vasectomy.  In my ode to contraception, vasectomy receives a gold star.  It’s nearly 100% effective, it costs about the same as 6 months of birth control pills ($350 - $1000), and it’s an out-patient procedure.  Female sterilization, by contrast, is incredibly expensive ($1500 - $6000) and is significantly more invasive for the same effectiveness rating.  What’s worse is that post-female sterilization pregnancies (which do happen) have a much higher likelihood of being ectopic – a life threatening situation for the woman.  Yikes! 

Once I stopped breast feeding, my menstrual cycle returned to bleeding for 15-20 days and I was not willing to put up with that nonsense for the next 20 years of life.  In addition, I started taking a different medication that eliminated the pill, Depo-Provera shot, and the patch as options, because those medications release hormones all throughout the body.  I needed a low-level hormonal option that would be targeted to my reproductive system only.  I switched to the Nuvaring, as it was one of the few remaining choices.  The ring is inserted vaginally for three weeks and the body’s heat activates the hormone release; after three weeks, remove the ring and have menstrual bleeding.  I mail ordered Nuvaring in the winter and stockpiled the extras in the refrigerator; unfortunately, you cannot mail order Nuvaring in the summer because too much heat activates the hormones and therefore renders the ring ineffective when you actually need it. 

The Nuvaring worked like a charm at regulating my menstrual cycle and I rejoiced at the simplicity of a once-a-month method.  Unfortunately, I changed insurance companies and my $20 a month Nuvaring cost jumped to a hefty $60 a month.  $720 a year was a hefty price for menstrual cycle regularity.  Consequently, I started shopping for another option and discovered the IUD.

The IUD, or intra-uterine device, is inserted into the uterus and it is an over 99% effective birth control method that lasts for years.  The copper IUD, which is non-hormone based, lasts for TWELVE YEARS!  That’s just incredible.  The Mirena IUD, which is hormone based, lasts for five years, but my doctor assures me that it actually works for seven.  The Mirena costs $500 to $1000, depending on insurance, and requires a doctor who is trained in their insertion.  My primary care doctor was not trained, so I found another doctor to get the Mirena IUD.

The Mirena hurts to get in position and there’s no way around it.  Jabbing something through the vagina and cervix is a painful process but, luckily, my procedure took only about 10 seconds.  The benefits of the Mirena cannot be overstated.  The hormones are continuously acting; there is never a point where I’m not 100% protected against pregnancy.  Additionally, I only have to think about my birth control method once every five years, as opposed to once every day like with the pill.  And, for menstrual cycle regulation purposes, the absolutely best side effect of the Mirena is that 1 in 5 women stop menstruating all together.  I crossed my fingers that I would fall into that 20% category and I celebrated my good fortune when my menstrual bleeding lightened and then eventually stopped.  I’ve been menstrual cycle free for about a year now.

Since I am no longer menstruating, I’m also no longer experiencing the extreme emotional highs and lows that raging hormones cause.  Emotionally, I’m much more even keeled, and that is a wondrous development.  I’m looking forward to being in this steady state until menopause.  Many women balance the need for menstrual cycle regulation with their need for effective pregnancy prevention.  I am incredibly grateful that I found a method that provides effective solutions for both problems.  Thank you, Mirena!

Now, I am the lucky parent of two daughters who have inherited my genes and quite possibly my same menstrual irregularity problems.  I am not excited about enduring their hormonal emotional swings from the parental end, and I feel for them because I know how challenging the whole process is to experience. 

There are so many ethical questions regarding a child using contraception.  In many cases, I don’t want to give my daughters a choice.  As soon as menstruation begins, I want to start tapping them with the Depo shot or (even better) connect them with the copper IUD.  But, realistically, none of these options are great for a 14 year old girl whose parents want her to be protected well before she becomes sexually active.  Obviously, my girls will have the choice to use whatever method they prefer and I hope that they feel comfortable approaching me when the time is right.  I recognize that they will navigate much of the same path I did – no contraceptive choice is the right one for the entire 35 – 40 years span – but maybe they will have even better options that have not been created yet AND they will have insurance coverage that will make those options financially viable.  I sincerely hope so.