This post was written by Rebecca Hendrickson, FNP-C, PPG OB-GYN, Parkview Health.
According to a new report from the Centers for Disease Control and Prevention (CDC), the age of first-time mothers in the United States is steadily rising. In 2016, the average age was 28.7; it increased to 29.6 in 2023. While there are many factors behind this shift, one noteworthy contributor is the increased access to birth control and the ability to make informed decisions about whether and when to start a family.
To help you gain a clearer understanding of how these methods work and which ones may align with your goals, this guide breaks down some of the most common hormonal and nonhormonal contraceptives, along with key considerations to support your decision.
Hormonal methods
Hormonal birth control methods contain either estrogen and progestin in combination or progestin only. Some of these hormonal methods include things like combined oral contraceptives, progestin-only oral contraceptives, combination patches and vaginal rings. Other hormonal methods include an implant, intrauterine device (IUD) and injections.
Combined oral contraceptives (COCs)
This medication contains both estrogen and progestin and should be taken daily, ideally at the same time. Every COC user will have differing responses to the same medication, and it may take some trial and error to find an oral method that best meets the user’s needs.
Effectiveness
Approximately 9 out of 100 users who take COCs for one year will experience an unintended pregnancy. This is most commonly due to forgotten or missed pills.
Benefits
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Make bleeding lighter
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Minimize menstrual cramps or pain
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Decrease the risk of ovarian and endometrial cancer
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Lessen acne
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Reduce the risk of iron deficiency anemia
Side effects and risks
Some side effects include:
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Nausea
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Breast tenderness
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Mood changes
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Bloating
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Irregular bleeding or breakthrough bleeding if pills are forgotten
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Blood clots
Who should not take COCs
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Women aged 35 or older who smoke cigarettes
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Women who could be pregnant
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Individuals with a history of blood clots or a stroke
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Those who have a history of "estrogen-dependent" tumors
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Women with abnormal or unexplained menstrual bleeding
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Individuals who have active liver disease
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Those who experience migraines with aura
Patients with high blood pressure should be monitored frequently, as being on a COC can increase their blood pressure further.
Additional considerations
The hormone levels contained within COCs are much lower now than when this medication was first brought to the market, which, in turn, has decreased the risk of blood clotting. Literature also shows that there is a higher risk of blood clots in women who are pregnant or soon after giving birth in comparison to COC use.
Progestin-only oral contraceptives
Also known as "mini-pills," this option contains only progestin, a synthetic form of the hormone progesterone. These are a good choice for women who cannot take estrogen.
Effectiveness
When mini-pills are taken exactly as directed, they are more than 99% effective at preventing pregnancy. However, this method has a slightly higher failure rate due to the timing sensitivity of these pills. They should be taken at the same time each day, and if they are missed, a backup contraceptive should be employed.
Benefits
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More effective than barrier methods alone
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Cause fewer side effects than COCs
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They don't contain estrogen
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Safe to use while breastfeeding
Side effects
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Irregular menstrual bleeding and spotting
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Acne
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Breast tenderness
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Decreased libido
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Headaches
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Nausea
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Ovarian cysts
Most patients experience similar side effects to COCs, but there is minimal to no risk of blood clotting due to the absence of estrogen.
Who should not take progestin-only oral contraceptives
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Individuals who experience unexplained abnormal vaginal bleeding
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Those with a history of liver cancer, liver tumors or other diseases of the liver
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Anyone who has or ever had breast cancer
Nexplanon implant
Nexplanon® is a small flexible rod containing the hormone progestin. In a clinical setting, a certified provider inserts it under the skin into the inner upper arm.
Effectiveness
Implants are more than 99% effective in preventing pregnancy. Nexplanon is approved by the U.S. Food and Drug Administration (FDA) for up to 3 years, but some studies show that extended use of the implant safely prevents pregnancy for up to 5 years.
Benefits
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One of the most effective methods of birth control
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It's safe to use while breastfeeding
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The implant doesn't contain estrogen
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It's convenient and low maintenance
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It may reduce heavy bleeding and cramping
Side effects and risks
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Minor bleeding, pain and bruising at the insertion site
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Migration or injury to other structures if the placement is not done subcutaneously
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Irregular, unscheduled bleeding or spotting between periods
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Mood swings or depressed mood
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Decreased libido
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Acne
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Headache
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Weight gain
Who should not use implants
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Individuals with a history of blood clots such as deep vein thrombosis or pulmonary embolism
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Anyone who currently has or ever had breast cancer
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Those with severe liver disease
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Current smokers
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Women with heart disease
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Women under the age of 18 and over the age of 40
Additional considerations
If the patient tolerates the implant well, it does not need to be removed until 3 years. However, it can be removed at any time if family planning needs change or if the patient would like to exchange methods. Nexplanon users usually begin to ovulate within a month after these devices are removed.
Hormonal IUD
This is a small device that is inserted into the uterus by a trained provider in a clinical setting. Over time, it releases small doses of progestin in order to prevent pregnancy.
Effectiveness
Hormonal IUDs are more than 99% effective in preventing pregnancy. While 1 in 10 women will not tolerate the IUD due to side effects or discomfort, most can keep the device in place for several years after the insertion procedure.
Hormonal IUDs prevent pregnancy for 3 to 8 years, depending on which IUD is used. These options include:
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Mirena® and Liletta® are effective for 8 years
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Kyleena® is effective for 5 years.
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Skyla® is effective for 3 years.
Benefits
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Long-lasting
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IUDs don’t contain estrogen
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Low maintenance
Side effects and risks
Using an IUD is safe and rarely causes problems. Perforation is rare, but when it occurs, it's almost always during insertion. After insertion, some women experience the following:
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Sweating
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Pale skin
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Fast heartbeat
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Fainting
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Dizziness
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Cramping
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Bleeding
Other risks associated with use include
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Abnormal bleeding
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Infection
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Increased risk of pelvic infection in the setting of an indwelling IUD with an STI
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Expulsion within the first few months
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In the event of pregnancy, there is an increased risk of ectopic pregnancy.
Who should not use an IUD
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Individuals with current pelvic infections or untreated STIs
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Women with unexplained vaginal bleeding
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Those with a history of uterine abnormalities
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Women who have a history or increased risk of certain cancers
Additional considerations
Some progestin-releasing IUDs can reduce bleeding by up to 80%, with Mirena specifically FDA-approved for the treatment of heavy menstrual bleeding. However, it is not uncommon for users to experience irregular or heavier bleeding during the first few months after insertion. This should improve over time. Fertility should return immediately upon removal.
Injectable
Depo-Provera® is a long-acting injectable contraceptive containing progestin. This medication is administered into a muscle, such as the buttock or upper arm, by a healthcare provider once every three months.
Effectiveness
With perfect use, this method is 99% effective. However, real-world effectiveness is about 96% due to delays in receiving injections on schedule.
Benefits
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It's safe to use while breastfeeding.
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The shot may reduce heavy bleeding and cramping.
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The shot doesn't contain estrogen.
Side effects and risks
This medication has a black box warning about the risk of osteoporosis. Calcium supplementation and regular weight-bearing exercise can minimize this risk.
Other side effects of this medication include:
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Irregular or prolonged bleeding during the first few months of use
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Approximately 50% of users stop having menstrual cycles after one year of use
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Changes in mood, including increased nervousness and/or irritability
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Weight gain
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Headaches
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Acne
Who should not use the shot
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Women with osteoporosis or heightened risk for bone loss
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Individuals who experience undiagnosed vaginal bleeding
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Those diagnosed with liver disease
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Women with a history of breast cancer
Additional considerations
In most cases, menstrual cycles should return within six months after stopping this medication. However, some individuals may not have their periods for a year or more. This should be considered when planning for a family.
Vaginal rings
These flexible rings are inserted into the vagina and contain both estrogen and progestin. There are a few types, and care instructions differ slightly between them.
In most cases, it is easy to insert and remove, and the user cannot feel it in place over time, nor their partner during intercourse. The ring stays in the vagina for three weeks and then is left out during the fourth week to allow for a menstrual cycle.
Effectiveness
When the ring is used exactly as directed, it is more than 99% effective at preventing pregnancy. With typical use, it is only 93% effective, meaning that 7 out of 100 people will have an unplanned pregnancy.
Benefits
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The ring is more effective at preventing pregnancy than barrier methods of birth control
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It may reduce acne, heavy bleeding and cramping, and symptoms of premenstrual syndrome
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Easily reversible with regular ovulation returning within 1-3 months of stopping
Side effects and risks
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Breast tenderness
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Headache
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Nausea
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Mood changes
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Vaginal discharge, discomfort in the vagina and/or mild irritation
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Increased risk of blood clots, heart attack, certain cancers and high blood pressure
Who should not use vaginal ring
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Women with a BMI over 30
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People over age 35 who smoke
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Those with a history of blood clots, stroke or heart disease
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Individuals with migraines with aura
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Women with certain types of cancers
Additional considerations
The ring must be used consistently on a monthly cycle for continued effectiveness. If it is removed for more than three hours during the active weeks, backup contraception should be used. Most users regain fertility within a few weeks of discontinuation.
Skin patches
Xulane® and Twirla® patches contain both estrogen and progestin. Users wear them on the skin on the shoulder, upper back, abdomen or buttocks for one week. After one week, the patch is removed, and a new one is applied for a total of three weeks. Then, the patch is left off during the fourth week to allow for a menstrual cycle.
Effectiveness
When the patch is used exactly as directed, it is over 99% effective at preventing pregnancy. However, with typical use, its effectiveness drops to only 93%.
Benefits
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The patch is more effective at preventing pregnancy than barrier methods
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It may reduce acne, heavy bleeding and cramping, and symptoms of premenstrual syndrome
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It's easy to check to see if you forgot to put one on
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Easy to apply and replace
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Easily reversible with regular ovulation returning within 1-3 months of stopping
Side effects and risks
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Breast tenderness
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Headache
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Nausea
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Skin irritation
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Spotting/bleeding between periods
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Stomach pain
Who should not use the patch
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Women with a BMI over 30
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People over age 35 who smoke
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Those with a history of blood clots, stroke, or heart disease
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Individuals with migraines with aura
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Women with certain types of cancers
Additional considerations
If the patch becomes loose or falls off for more than 24 hours, reapply it or start a new patch and use a backup method of contraception.
Nonhormonal methods
Nonhormonal methods include the copper IUD, condoms, cervical cap, diaphragm and sponge.
Copper IUD
ParaGard® is the only hormone-free IUD and can remain effective for 10 years. This device is inserted similarly to the hormone-releasing IUDs in the office by a trained provider.
Effectiveness
Copper IUDs become effective immediately after insertion, while hormonal IUDs may take up to 7 days to become fully effective. Both devices are comparable to tubal ligation in pregnancy prevention and are more than 99% effective.
Benefits
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Long-lasting
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Does not contain estrogen
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Low maintenance
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It can be used as an emergency contraceptive
Side effects and risks
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Heavier, longer and/or more painful periods
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Increased risk of pelvic infection when an STI is present
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Risk of expulsion or perforation
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In the event of pregnancy, there is an increased risk of ectopic pregnancy
Who should not use the copper IUD
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Individuals with copper allergy or Wilson's disease
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Individuals with current pelvic infections or untreated STIs
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Women with unexplained vaginal bleeding
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Those with a history of uterine abnormalities
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Women who have a history or increased risk of certain cancers
Additional considerations
Because copper IUDs do not affect ovulation or the menstrual cycle, fertility typically returns immediately after removal.
Emergency contraception
Emergency contraception is a way to prevent pregnancy after unprotected vaginal sex. This only reduces the risk of pregnancy; if ovulation has already occurred, it cannot prevent the pregnancy.
It can be provided in the form of an IUD or pills and should be acquired as soon as possible after intercourse, ideally within 72-120 hours maximum. Oral medication can be purchased over the counter or online. If you need emergency contraception, you can reach out to your provider for assistance.
Effectiveness
An IUD is the most effective form of emergency contraception. It is inserted by a doctor and can almost always prevent pregnancy.
With emergency contraception pills, the sooner you take them, the more likely they are to prevent pregnancy.
Side effects and risks
An IUD may cause cramping and bleeding during the first few days after it's inserted.
Emergency contraception pills can cause
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Light bleeding (spotting)
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Earlier period to start a few days earlier or later than you expect
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Headache
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Nausea
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Stomach pain
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Dizziness
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Fatigue
Additional considerations
Emergency contraception should not replace regular birth control methods, except when using an IUD. Emergency contraception pills do not work as well as other regular types of birth control.
If you are at a higher weight, emergency contraception pills may not work as well to prevent pregnancy.
Surgical methods
Tubal ligation
This is a form of birth control that prevents pregnancy permanently. During this procedure, the physician will cut, block, clamp or remove the fallopian tubes. In current medicine, most physicians are removing the fallopian tubes, which significantly decreases the risk of ovarian cancer by about 60%.
Effectiveness
It is more than 99% effective.
Benefits
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Permanent, no need for ongoing birth control
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Highly effective
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Can be done at the time of a cesarean section or separately
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Tube removal may reduce the risk of ovarian cancer
Side effects and risks
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Infection
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Blood clots
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Bleeding
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Damage to surrounding organs (rare)
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Pain or discomfort during recovery
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Reversal is possible in rare cases but not guaranteed
Additional considerations
This is a surgical procedure performed in an operating room. You will need a comprehensive pre-operative appointment to assess your safety and receive lab work prior to surgery.
This surgery can be done in two ways—minimally invasive or open surgery. During your pre-operative appointment, your surgeon will discuss these options as well as the risks, benefits and aftercare of the procedure.
Male contraceptives
The primary forms of male birth control currently available are condoms and vasectomies. Although research is ongoing, there are no federally approved, widely accessible male birth control pills or hormonal methods comparable to those available for women.
Vasectomy
A vasectomy is a safe, effective and permanent method of birth control for men. During this outpatient surgical procedure, a provider cuts and cauterizes the vas deferens, the tubes that carry sperm from the testicles. This stops sperm from being released from the penis during ejaculation.
Effectiveness
Vasectomies are more than 99% effective at preventing pregnancy; however, it can take several weeks before all sperm are cleared from the reproductive system. Use another method of birth control until you have a follow-up sperm count test 2 months after the vasectomy.
Benefits
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It is less invasive and lower risk than tubal ligation
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It is the most cost-effective form of birth control, with most procedures costing half as much as tubal ligation
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Short recovery time
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A vasectomy won't change your sex drive or your ability to have sex
Side effects and risks
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Bleeding under the skin, which may cause swelling or bruising
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Infection at the site of the incision
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In rare instances, the vas deferens may reconnect, allowing fertility
Who should not have a vasectomy
Vasectomy is considered a permanent method of birth control. You should only consider having one if you have completed your family or are sure that you don't want children.
Additional considerations
The procedure takes approximately 30 minutes to complete and has a short recovery time of just 2-3 days. It is performed under local anesthesia at a doctor's office or clinic. Prior to the operation, you will likely have a consultation visit with your provider, who will explain the procedure and allow you to ask questions.
You can resume sexual intercourse as soon as you are comfortable, usually in about a week. But you can still get your partner pregnant until your sperm count is zero. After your sperm count is zero, no other birth control method is needed.
Final thoughts
In addition to understanding how each method works and who it may be best suited for, it's also important to consider your ability to follow the treatment regimen, the cost of treatment, convenience, impact on your cycle and future plans for pregnancy.
Also, keep in mind that some medications and natural supplements can reduce the effectiveness of certain contraceptives, so be sure to discuss any you're taking with your provider during your counseling appointment.
When you're ready to explore your options, we're here to help. For more information, visit our website here.
