Birth Control: Beyond the Pill

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Birth Control: Beyond the Pill

By Middlebury Campus

If you had sex education in high school, chances are you were a pimply fourteen year old who was too embarrassed to pay attention or absorb any information. Most of what you learned was probably heteronormative and geared towards basic pregnancy and STI prevention — either abstain or, if you must, use a condom. All other information you gleaned about sex came from side conversations in math class, parties and gossip in the bus on the way to soccer games.

It is no wonder that there are misconceptions about birth control and all the options.

While many college students’ knowledge of birth control is limited to the basics — the pill, condoms, and, as a last resort, Plan-B — a wide scope of birth control exists, from daily use options to ten year options with a range of factors determining whether they are right for you. While pregnancy prevention is only applicable in heterosexual sex, contraceptives can be useful to women regardless of their sexuality. Your choice of contraceptive is determined by a variety of factors — STI prevention, pregnancy prevention, and a range of other reasons one might decide to use birth control.

Although there is no J-term workshop to take on birth control options, the College provides a variety of resources to students choosing what is right for them. At Parton Center for Health and Wellness, Senior Nurse Practitioner Laurel Kelliher provides many gynecological services, including pap smears, STI tests, and contraceptive consultations. She is trained to insert contraceptive devices and is able to prescribe the pill. Appointments can be made by calling the Health Center.

Additionally, Barbara McCall came on in June as the new director of Health and Wellness Education and specializes in sexual health, particularly women’s and LGBTQ health. Her office in McCullough marks the importance of student interaction in McCall’s job, where she is happy to chat with students about questions they have or problems they may be facing.

To fill in the gaps in many students knowledge of birth control, the Campus investigated the forms of birth control that you may not know about in this special feature.

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Birth Control is a Misnomer

“The name in itself is terrible,” Kelliher said. “It’s probably not well known, but I certainly do have women come in here and I’m not always aware of their sexual preferences and they’re coming in strictly for really bad cramps, their periods last for seven days and they’re sick of it; they’re done. And it may not be at all related to being sexually active or getting pregnant.”

Birth control keeps women from becoming pregnant, but, really, it is a misnomer because it does so much more.

Because many forms of birth control are hormonal, there are many different reasons that women — whether sextually active or not, or whether engaging in heterosexual or homosexual sex — could benefit from or need to be on birth control. Women are prescribed hormonal birth control for a variety of reasons other than pregnancy prevention, ranging from heavy to painful or uncomfortable periods to acne to cyclic depression that comes with menstruation.

One non-contraceptive reason women may want to think about birth control is to regulate their periods. According to Dr. Anna Benvenuto, who works at Addison Associates in OB/GYN, “There’s no medical reason for women to have their period every month, so different kinds of birth control make women not have their periods or make their periods much lighter.”

Furthermore, risk of ovarian cancer rises the more a woman ovulates, and many contraceptives prevent ovulation.

“The risk of uterine and ovarian cancers is decreased with long term use of the pill because you’re not ovulating and your ovaries are resting,” Kelliher said.

Though some women may worry about the effects of long-term hormone use, in many cases, according to Kelliher, the benefits outweigh the downsides.

“If you look at the bigger picture of what we put in our bodies, I think that this is necessary at times and has some great benefits — peace of mind that you’re not going to get pregnant, it generally helps with acne — and I think that’s worth a lot to some people,” Kelliher said.

Some hormonal birth control, however, does not work for everyone. Kelliher cited mood swings, depression, tearfulness, and insomnia as symptoms that bring students to Parton to reevaluate their current contraceptive. These side effects can be addressed by switching pills or trying a non-estrogenic method. Weight gain, on the other hand, is not actually a side effect of most forms of birth control, except for the Depo-Provera shot with can cause a 10 to 15 pound weight gain.

“Unfortunately, some people will come in … and say I’ve gained 30 pounds on the pill, and it’s really hard to sit here and tell the person that it’s probably not from the pill,” Kelliher said. “It’s probably because your eating habits have changed, you’re not exercising, you’re drinking more alcohol here.”

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The Best Birth Control

“I always get asked that question when I teach sexual health workshops. ‘What is the best form of birth control?’” McCall said. “And the answer is whatever is the best kind for you. It’s different for every person.”

Kelliher usually starts with a chart that lists different birth control options.

“A lot of times I’ll just get a sense from the patient of what they’re interested in,” Kelliher said. “Most women will say the pill. And I’ll say, ‘do you want me to talk about any other options because there are so many now.’ The birth control pill is great, but there are certainly a lot of different things.”

For college students, the most common options include intrauterine devices (IUDs) (both hormonal and nonhormonal), the implant, the ring, the pill and condoms.

“I think for most college students, the goal is a super reliable form of birth control that has minimal input,” said Benvenuto. “That’s just the reality of it. Day-to-day lives are really different, so remembering to take a pill at the exact same time every day, for example, is really hard for people.”

The wiggle room on the pill is small. Kelliher tells patients to take the pill within an hour each day, although odds are good if you take it within two or three hours.

“But it is 92% effective because of that human error,” Kelliher said.

The implant and the IUDs, on the other hand, require one time insertion without additional maintenance.

The implant, or Nexplanon, is inserted into the arm, where it is more than 99 percent effective at preventing pregnancy. This 1.6 inch rod releases a steady low-dose of hormone for three years and can be removed at any time if the user decides she would like to become pregnant. Although side effects may include breakthrough bleeding and random spotting, after three months, 20 percent of women stop menstruating entirely. Moreover, this procedure is less invasive than that required for an IUD. Kelliher was recently certified to insert them, although they are not yet available at Parton.

Insurance complications are also influencing Parton’s ability to provide birth control on-site. While they can write prescriptions for the pill or the NuvaRing, patients seeking IUDs and implants must be referred elsewhere.

Kelliher is trained to insert both devices, but because of the Health Center’s billing plan, they have yet to find a supplier. Visits to the Health Center are incorporated into the tuition, so they do not do on-site billing. For STI tests and other billable procedures, students pay out of pocket and are later reimbursed by insurance companies. With a high upfront cost for IUDs and implants, this strategy is more complicated.

“These are probably $600-700, and we can’t just buy that for you,” Kelliher said, who hopes they will figure out a better strategy this summer. “In the short term, it is really simple to figure out how to get an appointment at Porter Hospital OB/GYN or Planned Parenthood.”

The Mirena, a hormonal IUD that is over 99 percent effective in preventing pregnancy for five years. Mirena requires a simple insertion that, similar to the implant, can be done at Porter and Planned Parenthood. The plastic T sits in the uterus where it slowly releases hormones that inhibit sperm from fertilizing the egg. Mirena does this by thinning the uterine lining and thickening cervical mucus to prevent sperm from entering the uterus. It also changes periods in many cases, reducing bleeding in 90 percent in women by the sixth month, though short-term side effects may include cramping and spotting.

For those more wary of hormonal treatment, the ParaGard is non-hormonal copper IUD that is as effective as both the implant and the Merina and lasts for 10 years. Beyond concerns about the result of bodily hormones, women with epilepsy or who cannot tolerate hormones can still have long-lasting, low maintenance birth control through the ParaGard.

The NuvaRing is also often used by women who do not want a daily pill, but want more control than offered with an IUD or implant. NuvaRings are falling out of favor due to recent links with blood clots, though Benvenuto is not ready to close the door.

“If you look at every type of birth control out there, there will be lawyer ads looking for lawsuits for people who’ve had blood clots … so yes, there are reports of women getting clots on the NuvaRing, but there are reports of women getting clots with birth control pills,” Benvenuto said. “The issue is that for women going on birth control — any sort of hormonal birth control — it uncovers a sort of inherited risk of blood clotting disorders that is even higher in pregnancy. So pregnancy has a much bigger risk of a blood clot than any birth control you may use.”

Condoms are also an important part of pregnancy prevention and sexual safety, since none of the aforementioned methods protect from sexually transmitted infections (STIs). Male condoms are 85 to 98 percent effective in preventing pregnancy, and most of the error comes from improper usage. They, therefore, can always be used as a second form of contraceptive to even further reduce risk of pregnancy.

It is also always important for sexually active students to be tested at least once a year if they have multiple partners. One in four college students will contract an STI, with gonorrhea and chlamydia being the most common STIs.

As for birth control methods that are not recommended, Benvenuto cautions against “pulling out.”

“I’ll just put a plug for what I see a lot, which is people’s thoughts about the reliability of ‘pull and pray,” she said. “I’m just going to say that is not reliable for anything. There is actually sperm and semen in preejaculate, so people think they’re protected, and they’re not. I see people of all levels of education and all ages thinking this is a reliable form of birth control.”


A Man’s Responsibility

Other than male condoms, the responsibilities of pregnancy prevention lie in the hands of women — it is up to women to take the pill at the exact same time every day, it is up to women to research and decide which form of birth control works best for their lifestyle and body. So, what is the role of a male bodied man in a heterosexual relationship?

“There’s an important tension between agency and self-governance over a woman’s own body and negotiating safety, values and priorities in a relationship, and that’s going to look really different depending on the level of that relationship, how casual it is, how serious it is, the priorities of both people,” McCall said.

In other words, it isn’t an easy line to walk an Regardlessd there isn’t a black and white answer regarding this tension and how to navigate it.

of monogamy and commitment level, there are steps that everyone should be aware of to prevent pregnancy, though.

“It always astounds me how many folks, regardless of gender, don’t know the proper steps for how to put on a condom,” McCall said. “They sometimes wing it, based on what they’ve seen or what they’ve heard, but there are many steps that folks take that really insure safety.”

Another way men can proactively promote sexual health is by getting Gardasil, the HPV vaccine. The vaccine has been on the market for women since 2006, but many men do not know they can be vaccinated too because approval came later, in 2009. The shot is available at the Health Center and involves three doses over a six month period, a series that for some students is hard to complete, despite the protection from certain types cancer and genital warts it provides.

“I see very few men coming in for it,” Kelliher said. “Certainly more in the gay population for men — they’re more aware of it — but the heterosexual men are not.”

The Gardasil vaccine is covered by insurance until age 25, so Kelliher encourages all students to ensure they are up-to-date.

Obamacare and Birth Control

The Affordable Care Act recommends that all birth control be free, but in practice it depends on what your specific insurance plans cover, though all companies must cover birth control in some capacity. This could make a huge difference, particularly because devices like the implant can cost up to $700 without insurance. Under some insurance plans, patients only need to pay their normal co-pay for the visit to the doctor.

Additionally, young people can now stay on their parents’ insurance plan until they are 26, prompting some people to choose long lasting options, like an IUD or an implant, while they are still covered.

In light of recent legal challenges, many parts of the ACA are still up in the air, with many patients exempt depending on their insurance, and it could take up to five years for parts to be set in stone. In the meantime, the best course of action for students seeking insured birth control options is to check with their health care provider.

LGBTQ Specific

According to McCall, the population of women who traditionally has less access to birth control and to healthcare in general are queer women, or women who identify as LGBTQ.

“Folks who identify as LGBTQ are far less likely to seek access to healthcare, even when they really need it,” McCall said. “And this has to do with stigma and discrimination in the healthcare arena.”

Because health care visits can be more uncomfortable for people who identify as LGBTQ for a variety of reasons, queer women just aren’t aware of other reasons to take birth control, other than pregnancy prevention.

“A lot of [queer] people aren’t on birth control,” said Katie Linder ’15, co-chair of Queers & Allies (Q&A). “So with things like really heavy periods that are uncomfortable, they’re just like, ‘that’s the way it is,’ because they don’t have a doctor to talk about it with. There could be more awareness about other reasons you’d want to take the pill.”

Additionally, as stated before, contraceptives that prevent ovulation decrease risk of ovarian cancer. Queer women, therefore, could benefit from forms of birth control other than the pill, such as Nexplanon, which significantly decreases or even eliminates a woman’s period for three years.

“There are so many reasons that women can and should take [birth control],” Linder said. “… I was reading an article recently about lesbians having higher rates of ovarian cancer because they’re less likely to be on the pill … I thought that that was really interesting.”

Regardless, queer women’s health issues and difficulty accessing LGBTQ friendly doctors make it difficult to even know that hormonal birth control is an option for women who aren’t engaging in heterosexual sex.

“I was looking at, which is a queer women’s website that has stuff on almost everything … and I was sure that there was going to be at least one health related article about this but there wasn’t,” Linder said. “There is a void of knowledge on the internet.””

When All Else Fails

Even with all these birth control options, things can still go wrong.

Plan-B is 75 to 89 percent effective if taken within three days of having unprotected sex, although the effectiveness decreases quickly with time. Plan-B is available at Parton for $14 and over the counter at pharmacies for $50, but students can also have a prescription written at Parton to have insurance cover it.

“I recommend students have two prescriptions written,” McCall said. “Drop one off at your local pharmacy and have it on file in case you need it, and keep the other one with you in case you’re somewhere else and need it filled.”

Plan-B, however, is not effective for all women. The efficacy decreases for women with BMIs over 25 percent or who weigh more than 175 pounds, regardless of BMI. In these cases, ella is the best option.

Ella is not available at any pharmacies in Middlebury, although Planned Parenthood hopes to have it in stock soon. In the meantime, women can order ella online for $40 and have it rush delivered after an online medical consultation. Ella also works for up to five days, making it a more effective option for delayed pregnancy fears.

All emergency contraception pills, however, can be painful, involving side effects like vomiting and heavy and irregular periods that take a while to return to normal. They are also less effective the more often they are taken. Students, therefore, should always use preventative forms of contraception before sex and use these options as a last resort.

A less known option for emergency contraception is to have an IUD inserted immediately after unprotected sex, for which the window is approximately five days.

“It involves calling your provider’s office and getting an appointment for that day,” McCall said. “But usually when you let people know that’s what you need it for [an IUD for emergency contraception], they’re pretty swift about it.”

This option has the added benefit of future pregnancy prevention to avoid the panicked morning after feeling for another five-to-10 years once the IUD is inserted.

In the event that pregnancy does occur, students can seek help at Parton, where they can evaluate their options. At Porter OB/GYN, Benvenuto’s practice, students can seek obstetrical medical care if they decide to keep the child. If they decide not to, abortions are available at the Planned Parenthood in Burlington. The College offers resources, both medical and emotional, for students dealing with these decisions or any other decisions relating to sexual health and safety.

“Sex is an act of trust, whether you know somebody a little bit, a lot, or not at all,” McCall said. “There’s always a risk … I hope folks can be informed about what their options and choice are and the potential consequences, and they can choose the amount of risk that feels comfortable for them.”


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