Last partial update: July 2016 - Please read disclaimer before proceeding.
Avoiding unplanned pregnancy
Unplanned pregnancy is common in women in general but especially in young women. It almost always is presents a very difficult problem for the woman concerned, who is confronted with, either terminating the pregnancy and suffering the associated the psychological trauma, which can go on for many years after the actual termination, or overcoming the difficulties of giving birth to and bringing up an unplanned child. (This is especially a problem for teenage pregnancies where 60 per cent of women who choose to become mothers have no male partner.)
While no exact figures exist, it is estimated that about 85,000 abortions occur in Australia each year (about one in five of all pregnancies).The majority occur in young women, with about 17 per cent in teenagers and 47 per cent in women in their twenties.
About 20 per cent of Australian women will become pregnant in their teenage years, with the rate being about 44 per 1000 female teenagers per year. While some of these are planned and wanted, about 53 per cent (or 23 per 1000) end in termination.
This teenage termination rate is the sixth highest amongst OECD countries and does not compare favourably with many other developed countries. For example, the rates for German (5.3 per 1000 per year) and Dutch (3.9 per 1000 per year) teenagers are less than a quarter of those for Australian teenagers. (1996 figures)
This is perhaps not overly surprising when you consider that about 50 per cent of first time sexual intercourse in Australia occurs without any contraception being used.
Interestingly, the situation does not improve greatly as women get older. The overall termination rate in Australian women aged 15 to 44 years is similar at about 20 per 1000 women per year. Overall, almost 20 per cent of Australian women will have an abortion at some stage in their lives.
From the above it is obvious that contraception use in Australia needs to improve.
Contraception is still mostly left up to women
Contraception in Australia is still mainly left up to the female. This is very understandable as it is primarily women who face the consequences. In order to avoid becoming pregnant, a woman must;
a. choose a reliable form of contraception that suits her
b. use it properly all the time.
(Contraception also often needs to help prevent sexually transmitted diseases.)
a. Choose a reliable form of contraception that suits her.
There are many different forms of contraception available. Most are very good at preventing pregnancies but none are perfect. For example, the oral contraceptive pill has, overall, about a 96% success rate. This means that if 100 women used the pill as a contraceptive for a year, about four would become pregnant.
All forms of contraception have side effects and problems related to their use and these will play an important part in the decision about which to choose. These will be discussed when each form of contraception is examined. (Also see the summary table below.)
b. Use it properly all the time
Failure of contraception is a big problem. In a recent study of Australian women seeking an abortion, about 14 per cent stated they were using the pill at the time. Most forms of contraception work well when used properly all the time. However, it is the nature of much sexual intercourse to be unplanned and at times even opportunistic, often depending on the mood of the participants. While, for some, this is part of what makes it exciting, it does not help with planning successful contraception. The main reasons that contraception fails is that it is not used properly. Studies have shown that about 50 to 75 per cent of women taking the pill miss at least one tablet per cycle and about 20 per cent miss two or more pills per cycle.
Compliance with taking the pill: Studies have shown that about 50 to 75 per cent of women taking the pill miss at least one tablet per cycle and about 20 per cent miss two or more pills per cycle. If you take the pill do not underestimate the difficulty in taking it properly. To help with this, two alternative methods of taking the pill have been developed; vaginal ring and patches applied to the skin, both of which are used weekly rather than daily. (See later for detailed information re these choices.)
Alcohol is the biggest risk factor for contraception failure. When you add alcohol (and sometimes other illicit drugs) into the ‘sex equation’, you are liable to get even more spontaneous and unplanned sexual activity happening; which in some people is the reason for its consumption.
Contraception that relies on taking the contraceptive measure at the time, such as the appropriate use of condoms, is much more difficult to put into practice when alcohol and other drugs use is involved. Barrier methods are essential for protection against sexually transmitted disease and should be used all the time by couples who are not in a long term relationship. However, alone, they are generally considered as being not reliable enough as a means of contraception for anyone having sex more than very occasionally and this is especially the case when the couple consumes alcohol before sexual activity; and in Australia that is most couples. Some other more effective form of contraception that is not administered at the time of sexual intercourse needs to be used also.
The best contraceptive choices for different age groups
The adolescent and younger women
- Condoms (male and female)
- The combined oral contraceptive pill (COCP)
- Alternative, more convenient systems to deliver pill hormones
- Vaginal rings
- Transdermal (skin) patches (
- Progestogen implants (inserted under skin) 'Implanon' – younger women seem to find this option less attractive as it Is associated with menstrual irregularities and mood disturbance)
Women planning pregnancy in the near future
- All the above methods are suitable for this group. The main concern is to avoid ling acting contraceptives that are difficult to reverse, the main one being injectable, progestogen-only contraceptives.
Women breastfeeding
- Breast feeding
- Breast feeding itself does usually stop periods and works reasonably as a contraceptive. (During the first six months it has a success rate of about 98% as long as the baby is being exclusively breast fed and periods have not recommenced. However, this is often a time that women definitely do not want to become pregnant and for these women it is often best to use another form of contraception.
- Minipill
- Male condoms
- IUDs
- Progestogen implants (inserted under skin) 'Implanon'
Younger women who do not wish to have another pregnancy
- Male or female sterilisation
- IUDs, especially progestogen-containing IUDs as they reduce menstrual bleeding (IUDs are less suitable for women who have not had a baby as they are more difficult to insert.)
- Progestogen implants (inserted under skin) 'Implanon'
- The combined oral contraceptive pill (COCP) The presence of oestrogen in the COCP makes this form of contraception a relatively more risky choice as women get older, especially if they have risk factors for cardiovascular disease (heart attacks / strokes) or clotting disorders. However, the COCP does help control hot flushes and reduces menstrual bleeding, which can be excessive at this time.
Women in their 40s and peri-menopausal women
- Male or female sterilisation
- Progestogen implants (inserted under skin) 'Implanon'
- IUDs, especially progestogen-containing IUDs as they reduce menstrual bleeding (IUDs are less suitable for women who have not had a baby as they are more difficult to insert.)
- Progestogen-containing IUDs (e.g. ‘Mirena’) - These work well, last a long time, contain no oestrogen, and act to significantly reduce menstrual bleeding. Their use in the United Kingdom has reduced the need for hysterectomy to control dysfunctional uterine bleeding by about 40%. Copper IUDs increase menstrual bleeding and thus are not often used in this age group.
- The COCP – For selected women, low-dose oestrogen COCPs are an option up to two years post menopause (use in women over 50 is not recommended). Smokers and woman at increased risk of cardiovascular disease should not take the COCP after the age of 35 years and for other women over the age of 50 years, the risks associated with taking the COCP is greater than its benefits (such as reduced risk of ovarian and pregnancy complications).
Note: Hormone replacement therapy, used for reducing menopause symptoms, is not effective as a form of contraception.
Contraception options – A quick summary
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Hormonal methods – Combined oestrogen and progestogen ('The Pill') |
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Type of contraception |
Effective-ness* |
Age group suitability |
Advantages |
Disadvantages |
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Combined oral contraceptive pill |
99% ( with perfect use) 92% with typical use |
Suitable for all women |
Does not rely on use at time of intercourse |
No protection against STDs |
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Vaginal ring (NuvaRing) |
99% (with perfect use) 92% with typical use |
Suitable for all women |
Ease of use (Inserted once per month.) |
No protection against STDs |
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Contraceptive patch |
97% (with perfect use) 90% (typical use) |
Should probably not be used in older women as the oestrogen dose is higher than that in the COCP |
Ease of use (Applied once per week.) |
No protection against STDs |
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Hormonalmethods – Progestogen only |
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Type of contraception |
Effective-ness* |
Age group suitability |
Advantages |
Disadvantages |
|
Minipill |
97% (with perfect use) 94% typical use |
Women who are breast feeding |
Does not rely on use at time of intercourse |
No protection against STDs |
|
Implanon (Progesteron rod inserted under the skin) |
Over 99% |
Suitable for all women |
Very effective |
No protection against STDs |
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Progesterone Intrauterine device |
99% |
Women who have had a baby. |
Ease of use once inserted. |
Generally not suitable for use in women who have not had children |
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Barrier methods |
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Type of contraception |
Effective-ness* |
Age group suitability |
Advantages |
Disadvantages |
|
Male Condoms |
98% (perfect use) |
Suitable for all women |
Protection against STDs |
Relies on proper use at time of intercourse |
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Female condoms |
95% (perfect use) |
All women although may be harder to use in six months after having a baby. |
Protection against STDs |
Relies on proper use at time of intercourse |
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Diaphragms |
94% (perfect use) |
All women |
No side effects |
No protection against STDs |
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IntraUterineDevices |
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Type of contraception |
Effective-ness* |
Age group suitability |
Advantages |
Disadvantages |
|
Copper Intrauterine device |
95% to 98% |
Women after they have had a baby |
Ease of use once inserted. |
Generally not suitable for use in women who have not had children |
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Progesterone Intrauterine device |
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Other less effective methods |
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Spermicides alone or |
These methods are all too unreliable to be recommended as adequate forms of contraception. |
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*% of women who avoid pregnancy each year with continuous use of this form of contraception for the whole year. (For example, a score of 96% means that 4 out of every 100 women using that form of contraception would get pregnant each year.)
Some forms of contraception are not used perfectly in many situations and thus the typical figure quoted may well be a more appropriate one to base your contraceptive decision on.
Contraceptives using female hormones
There are two basic types of contraceptives that use female hormones.
A. Those using both an oestrogen and a progestogen
- The combined oral contraceptive pill (COCP), usually just called ‘the pill’.
- Vaginal rings incorporating both types of hormone
- Transdermal (skin) patches that use both types of hormones
B. Those using a progestogen alone
- The minipill
- Implanon. A small progestogen containing rod that is inserted under the skin
- An Intrauterine device (IUD) that contains a progestogen
- Injections of long acting progestogens
The Combined Oral Contraceptive Pill (COCP) (commonly just called ‘The Pill’)
Types of COCP.
By far the most common contraceptive used is the COCP, which is usually just called 'The Pill'. It is made up of two hormones, oestrogen and progestogen. Oestrogen and progestogen are the two types of main female sex hormones occurring naturally in the body. There are numerous different types of synthetic (woman/man-made) oestrogen and progestogen that are used in the COCP and thus there many different versions of the COCP, according to the type of oestrogen and progestogen being used and the amount.
a. The COCP gives a 28-day cycle:
At present, all COCPs work on a 28-day cycle. Active hormone containing tablets are usually taken for 21 days and then either no tablet is taken for the remaining 7 days (in the case of packs containing only 21 tablets per month) or sugar tablets are taken for the seven days (in the case of packs containing 28 tablets). The reason that 28 day packs exist is to keep women in the habit of taking a pill each day. (Taking medication is difficult for all people to remember, men and women, and this task should not be underestimated. Remember that at least 20 per cent of women on the COCP forget at least one tablet per month; and this unfortunately is the main reason why about one third of unplanned pregnancies occur in women taking the COCP as a mans of contraception.)
Some types of COCP have the same concentration of each hormone in all 21 active tablets in each pack while others vary the amounts.
Packs containing 24 active tablets and 4 inactive tablets: Packs containing 24 active tablets are now also available. (e.g. ‘Yaz’). These packs have the advantage of reducing daily oestrogen dose and thus oestrogen side effects such as breast tenderness without reducing the likelihood of pill failure and pregnancy. They also reduce the likelihood of failure and pregnancy due to a missed pill.
Creating longer cycles by missing inactive tablets: When using packs where the active tablets are all the same, it is not uncommon for doctors to advise women that it is alright to just take active tablets for two to three cycles without a break. This can reduce the number of ‘periods’ to about four per year without significantly increasing the pill failure / pregnancy rate. (Packs with this type of pill regimen are available in Europe.) As well as reducing period number (and thus menstrual blood loss), this technique reduces the likelihood that a missed pill will result in pill failure / pregnancy. Periods when they occur can also be less painful and result in less bleeding.
Taking active tablets continuously should not be done for longer than this as it is quite likely to result in unscheduled ‘break-through’ bleeds. The main reasons that this regimen is not more commonly recommended is that such break-through bleeding is more likely to occur and it can make the diagnosis of a pregnancy that has occurred on the COCP more difficult. (Remember that occasionally women who become pregnant while taking the COCP can still have slight periods early on in the pregnancy.)b. Low dose COCPs
In an effort to reduce pill side effects and simulate more natural levels of body hormones, the amount of the oestrogen in COCPs has been gradually reducing over the years. In older women, where oestrogen side effects are more of a concern, they are certainly the preferred COCP option. Low dose pills that are commonly prescribed today are certainly easier to take but the trade-off (there always is one!!) is that the safety margin regarding pregnancy prevention is less. Thus, missing the odd tablet is a risky. The dose of oestrogen in modern low dose COCPs is about 20 micrograms of ethynyl oestradiol or less, although less than 30micrograms is considered a low dose.
How does the COCP work?
While there are many versions of the COCP, they all act to prevent pregnancy in the same way; that is, by stopping a woman's ovaries from releasing an egg cell each month, which means that a pregnancy cannot begin. They do this by providing a higher level of oestrogen and progesterone than is normally present in the body and this inhibits the body’s production of the female sex hormones that are responsible for egg development and release. (This is what actually happens during pregnancy, where higher natural levels of oestrogen and progesterone inhibit egg release as there is no need for them during pregnancy.) They also act by ithickening cervical mucous and by preventing implantation of fertilized eggs, should egg release occur.
Menstrual periods on the COCP: The COCP also takes over control of when menstrual periods occur. Normally, this is under the control of oestrogen and progesterone produced by the body and it is a natural monthly sudden drop in the level of these hormones that causes menstrual periods. The COCP acts to suppress body production of these hormones and creates an artificial period by mimicking this sudden drop in hormone levels. (This occurs during the seven day sugar tablets or no tablet period, where no active hormones are administered.) This withdrawal of oestrogen and progesterone from the body causes the lining of the uterus to shed, which is what a menstrual period is. (It is termed a withdrawal bleed because it is caused by hormone withdrawal.)
No longer than seven days without active ‘hormone-containing’ tablets
It is important that the period when no active hormone is taken is not longer than seven days, otherwise the normal body hormone system starts to work again and egg release may occur.
Do I need to have a period every month on the pill?
At present, COCP packs are designed to give a withdrawal bleed with each 28 day cycle, with bleeding usually commencing about 3 days after the last active hormone-containing tablet is taken. This has been done to reassure women that things are normal and that they have not become pregnant during the cycle. (It is worth mentioning here that, very occasionally, women can still have slight period type bleeding when they have become pregnant while still taking the COCP. So if you are suspicious that you might be pregnant, it is definitely worth checking even f your periods are still occurring.)
There is, however, no need for a woman to have a period-like withdrawal bleeding each month and it may well be that in the future COCP packs will be designed to give longer intervals between withdrawal bleeds. Increasing the length of the cycle up to about 49 days (from the present 28 days) has been shown to cause no difference in the withdrawal bleeding episodes that do occur. Cycles longer than 49 days are associated with an increase in episodes of slight bleeding between periods (‘break-through bleeding’ or spotting) but less bleeding with withdrawal bleeds that are supposed to occur when hormone tablets are stopped at the end of each cycle.
At present, it is possible to extend the length of cycles using most currently prescribed pills. (Talk to your doctor.)
Beneficial effects of the COCP
a. COCP and cancer
While the COCP reduces the risk of some cancer and increases (slightly) the risk of others, overall its use has a very positive effect in reducing cancer risk.
Cancer risk reduced by long-term (over five years of continuous use) COCP use
- cancer of the ovary by 50%
- cancer of the endometrium (lining of the womb) by up to 50%
- colorectal cancer by 20 to 40%.
Cancer risk increased by COCP use
- Breast cancer – Risk is increased slightly, but evidence for this association is less than perfect. (As an indication of the likely effect; if 10 in 1000 women have a diagnosis of breast cancer by age 45, using the COCP before this age would increase this rate to 11 in 1000.) The risk decreases after ceasing COCP use to approach the level of those who have not used the COCP 10 years after cessation.
- Cervical cancer – Slightly increased risk
b. Other very beneficial effects of the COCP
As well as preventing pregnancy, the COCP can have other very beneficial effects.
- It can reduce acne.
- It can reduce facial hair growth.
- It can reduce pain and bleeding associated with menstrual periods both in degree and length of time. Less bleeding can help reduce anaemia that occurs in women who have heavy menstrual periods.
- It can reduce the incidence of non-cancerous breast lumps, and cysts on the ovary.
- It can reduce the risk of getting a serious pelvic infection.
Some types of pill are better at helping with menstrual cycle symptoms and acne than others and it is best to discuss this with your doctor when selecting the type of pill you are going to use. You can also use the pill to purposely miss a menstrual period. Again you will need to talk to your do to about how to go about this.
The COCP in adolescence and young adulthood
Acne and to a lesser extent hirsutism (excessive facial hair growth) can be problems in adolescents and selecting a pill with a progestogen that has anti-androgenic (anti male hormone-like) effects can help these problems and indeed, the COCP is sometimes prescribed primarily for this purpose. The results, however, are somewhat unpredictable. The best progesterone for this purpose is cyproterone, usually used in a dose of 2mg in each tablet. It is, however, more likely to cause weight gain, breast tenderness and mood disturbances including mood swings and depression. If these side effects are a problem, then alternative progestogens include gestodene, desogestrel and drospirenone.
It generally takes about three months of treatment with the COCP for improvement in acne to occur.
Another important consideration for all women is mid-cycle bleeding and this is a common reason for younger women to stop taking the COCP. This can usually be prevented by not having too low a dose of oestrogen in the COCP and thus most younger women are prescribed COCPs with medium doses of ethinyloestradiol (the most commonly used oestrogen) of 30 to 35 micrograms in each tablet. The side effects of oestrogen are less of a problem in younger women and thus this dose of oestrogen is not a problem. In older women it is better to try to use the smallest dose of oestrogen possible.
Combined pills containing cyproterone acetate
(Brand names: Brenda 35-ED, Diane 35-ED, Juliet 35-ED). All these COCPs contain 35 micrograms of eithinyl oestradiol.
Combined pills containing drospirenone
(Brand names: Yasmin, Yaz) The COCP ‘Yasmin’ contains 21 active tablets with 30 micrograms of eithinyl oestradiol and the non-steroidal progesterone drospirenone. The COCP ‘Yaz’ contains 24 active tablets with 20 micrograms of eithinyl oestradiol and the non-steroidal progesterone drospirenone.
As well as reducing unwanted acne and facial hair, drospirenone also has a mild diuretic effect which helps reduce fluid retention symptoms associated with premenstrual syndromes, and is associated with less weight gain, which is a common side effect of the COCP.
Other delivery options for hormone contraceptive
Remembering to take a tablet each day is difficult for everyone and the hectic life that young people lead means they have a high incidence of forgetting medication. An option is to use longer acting delivery options, such as skin patches than need nly be applied once a week or vaginal rings that are inserted once a month.
Some women can not take the COCP
You should not take it if you:
- have had a deep venous thrombosis (blood clot), stroke or heart attack
- have severe liver problems
- have a migraine with visual disturbances starting before the headache (aura)
- have unusual bleeding from your vagina, that has not been diagnosed.
- are breast feeding
You may not be able to take the pill if you:
- have high blood pressure, diabetes, gall bladder disease, active liver disease, kidney disease, some blood problems, tuberculosis, severe depression, or are on some other medications
- have had cancer of the breast or cervix
- are over 35 and smoke, or you are under 35 and smoke more than 15 cigarettes a day.
You will need to tell your medical practitioner if any of the above apply to you.
Side effects of the COCP - Common less harmful side effects
As with any medication, there are side effects and these can be a considerable problem. About a third of women who commence the COCP cease use in the first year!! Many are relatively minor and transient. If they persist, then changing the type of pill can often help. The most common are as follows.
- Nausea
- Slight bleeding in between periods, often termed break-through bleeding or spotting. (This mostly occurs in the first few periods and then settles down.)
- Breast tenderness Again this tends to be less of a problem after a couple of months.
- Brown pigmentation on the face. This is due to oestrogen in the COCP and occurs with sun exposure. Wearing a hat will help and as can changing to a COCP with a lower dose of oestrogen or the minipill, which contains no oestrogen. The pigmentation is not permanent but can months to fade.
- Weight gain (usually only slight)
- Less uncommon side effects include headaches, reduced sex-drive and mood changes (feeling irritable).
Side effects – Very uncommon but more serious side effects
The COCP also increases very slightly the likelihood of more serious medical problems. It needs to be stressed that these problems are rare, especially in well young women, and are generally only a concern in older women, especially if they smoke or have an increased risk of these problems. (See above list of women who can not take the COCP.) For younger women, the physical and psychological consequences of an unplanned pregnancy far outweigh any increased risk of these conditions. The conditions that are slightly more common when taking the COCP are as follows.
- Increased blood clotting, which increases the risk of:
- clots in the veins in the legs (termed ‘deep vein thromboses’). This is the most common clotting problem and the only condition that young women who don’t smoke need to be wary of. Symptoms include swollen, painful calves and chest pain, coughing up blood or shortness of breath. (See your doctor if these occur.)
- Heart attacks and strokes (Sudden severe chest pain is the most common sign of heart attack. Severe headache, disturbance of speech or eyesight, numbness or weakness of your face or of a limb can be a sign of a stroke.) These conditions are really only a significant concern for ‘older’ women (over 35 years) with other risk factors for these conditions, such a smoking.
- High blood pressure
- Liver disease, mostly in people with existing liver disease
- Migraines
- Depression
- Gall bladder disease
Clots and using the COCP when having surgery or flying: With many types of surgery there is an increased risk of clotting. As the COCP can increase this risk further, doctors often advise women to go off the COCP for a month or so before having their surgery. Obviously other contraception needs to be used during this time. Clots in the lower legs can occur when flying. It is important to do regular leg exercises and drink plenty of fluids when flying long distances.
Starting the COCP
Generally, the COCP is commenced during a menstrual period. The exact day varies with each pack. The date that you are protected from becoming pregnant thus varies also and you will need to discuss this with your doctor. It is necessary to use condoms or some other form of contraception until the pill is definitely working and of course, those women who are not in long-term relationships need to use condoms EVERY TIME THEY HAVE SEX to prevent the risk of sexually transmitted diseases.
The ‘Quick-start’ technique
While it is not recommended practice (and the product is not licensed for this use), in some circumstances some doctors are happy to start the pill as soon as it is prescribed rather than waiting until the patient’s next period. (Women who would like more information about this option need to discuss it with their treating doctor.) It’s only real advantage is that it has been shown to increase compliance in some women.
Missing a tablet(s) - What happens?As already mentioned, missing a pill is very common and it is important to get into the habit of taking your pill at the same time every day and making sure that you always have a pack of pills with you. Having a spare pack in your travelling bag and a couple of spare tablets in your purse is a good idea. It is also a good idea to keep your prescription for repeats in your purse. Missing a single tabletIf the pill you missed was due to be taken less than 24 hours ago, you can safely take it straight away and take your next oil at the usual time. You will still be adequately covered with regard to contraception for the month. Missing more than one tablet in a row or missing several individual tabletsIf the tablet is more than 24 hours overdue (that is you have missed more than one tablet) or have missed one tablet more than once in the same cycle, still take a single tablet as soon as possible and resume taking your tablets with the next tablet that is due. However, you can not assume that the COCP will provide adequate contraception for this month and you need to use another form of contraception such as condoms (which of course many women will be doing anyway!!). You may also be at risk of becoming pregnant, depending on where you are in your cycle when you miss the pills. When am I most at risk of becoming pregnant if I miss more than one pill in a row? Starting a pill pack late:
If you start a pill pack more than 24 hours late and have had vaginal sex in the active hormone-containing pill break, you are at risk of becoming pregnant and should consider seeking emergency contraception (See later section.) Missing several hormone-containing tablets in a row may cause you to have a bleeding episode. |
Other times when the pill may not work
There are several occasions when the COCP may not work even though it is taken correctly.
- The COCP needs to be absorbed in the intestines and if you have significant diarrhoea or vomiting, then some of the hormone may be vomited up or may pass through without being absorbed.
- Some medications interfere with the effectiveness of the hormones in the COCP. This issue needs to be discussed with your doctor. Some antibiotics are a common cause and natural therapies can also be a problem.
During these times, other contraceptive measures need to be taken and continued for seven days after the problem has gone (or the other medication ceased). Again, if they occur during the early stages of a COCP pack and you have had vaginal sex recently, the need for emergency contraception should be discussed with your doctor.
Periods on the pill and pregnancy
As stated above, women can occasionally still have period-like bleeding when they have become pregnant while taking the COCP. The COCP is not perfect and if you are at all worried that you have become pregnant while taking it you should seek medical advice.
On the other hand it is not uncommon for women on the COCP to miss their monthly withdrawal bleed and much of the time this is not due to being pregnant. However, it is unwise to assume that this is the case and it is usually worthwhile doing a pregnancy test, especially the first time that this occurs.
Pregnancy after being on the COCP
Most women are able to become pregnant within six months of stopping the COCP. However, a small number do not get their periods after stopping the COCP and some of these women can have difficulty becoming pregnant. Any woman who has not had periods three months after stopping the COCP should seek medical advice.
The majority of these women usually had ‘problems’ with irregular periods before they started the COCP and thus are just resuming their previous irregular pattern.
Other methods of delivering the hormones (oestrogen and progesterone) contained in the COCP
As noted already, about 50 per cent of women miss one or more tablets each ‘pill cycle’. (It should be noted that most people find the task of taking medicines every day without fail difficult to adhere to.) With this in mind, easier methods of delivering the hormones contained in the pill have been developed, including a vaginal ring and a skin patch, which need to be inserted or applied only once a week.
These two new administration techniques are discussed below. It is necessary to read the section on the pill (above) before reading them.
Vaginal Ring (NuvaRing)
The NuvaRing is a soft plastic ring (about 55mm in diameter and 4mm in cross-section) that contains the same type of hormones as the COCP. (The oestrogen is ethynyl oestradiol and the progesterone is etonogestrel.) The hormones are slowly released over 10 days from the ring and absorbed into to the body through the vaginal mucosa.
As the hormones aren’t initially metabolised by the liver, a considerably smaller dose compared to the COCP (about 50% less) can be given and this reduces the likelihood of side effects such as breast soreness and nausea. It also makes it a better choice than the COCP for women close to menopause.
Administration / insertion
The ring is inserted by holding it between thumb and forefinger and placing it in your vagina. If it feels uncomfortable it can simply be pushed in further. The position is not critical and the vaginal muscles keep it in place, even during sex. Rarely, it can be expelled when straining to pass a bowel motion. (Unfortunately this is usually not noticed but as mentioned it is a very uncommon event.) It can be removed by inserting a finger into the vagina and pulling it out. Women used to using tampons should not have problems with its use.
A new ring is inserted before day 5 of the cycle (day 1 being the first day of menstrual bleeding) and is left in place for three weeks. It is then removed and a new ring is inserted a week later. Thus, a cycle similar to that provided by the pill is achieved.
The ring sits high in the vagina, usually at the back but positioning is not vital. It is better if the ring is left in place during sexual intercourse although it can be removed if it causes discomfort. (This is unusual.) If the ring is removed (or expelled), it needs to be replaced within three hours to continue providing protection. There is apparently a insertion demonstration available on ‘YouTube’.
Important - Incorrect use and pregnancy
It is important that the period where no ring is in place lasts no longer than 7 days; otherwise there is a risk of failure and pregnancy occurring.
This same problem occurs if the ring is removed for longer than 3 hours during the three-week cycle of hormone administration.
If either of these scenarios occurs and you have had vaginal sex in the past week, then emergency contraception is necessary and this should be discussed with your doctor. If you have not had sex in this period, then you need to use another form of contraception for the next seven days to avoid pregnancy or not have sex during this seven-day period.
Side effects and contraindications (Please read this section regarding the pill)
Side effects are similar to those of the pill, although they should be less noticeable (because the dose of hormone administered is less); especially breast soreness and nausea.
In addition to the pill’s side effects, the NuvaRing can also cause additional vaginal discharge to normal and occasional vaginal infections (in about 5% of users). About 15% of couples report feeling the ring during sexual intercourse but few found this a problem.
Contraindications are similar to those for the pill. (See above.)
Transdermal contraceptive patch (Ortha Evra patch) (Not yet available in Australia as at March 2009))
The ORTO EVRA patch, which is applied to the skin, is new method of delivering the hormones contained in the pill that is not yet available n Australia. (The oestrogen is ethynyl oestradiol and the progesterone is norelgestromin.) It is a 4.5cm x 4.5cm square in shape and can be applied to the buttocks, abdomen, upper arm and upper torso any part of the skin except the breasts. (It is most commonly applied to the buttocks.) It should not be applied to the breasts.
A new patch needs to be applied each week and the 28 day pill-like cycle is created by using 3 patches over 3 weeks and then having a week where no patch is applied. Each patch actually lasts for 10 days and thus this gives an added safety factor in case the woman forgets to change the patch on the correct day.
The patches generally attach well with few (about 4%) dislodging. This can be reduced by ensuring that cream (e.g. moisturing or sun cream) is not placed under the patch and cleaning the area of skin well before application. If a patch does dislodge it needs to be reapplied immediately and if it does not reapply fully it needs to be replaced.
If a patch is left off for more than 24 hours, another form of contraception needs to be used for the following week.
The withdrawal bleed occurs usually starts about four days after the start of the hormone free period and last 5 to 6 days, slightly longer than that experienced with the pill. There was also slightly more break-through bleeding (spotting) in the first three months.
Failure rates with typical use are thought to be slightly higher (about 90%) than that experienced with COCP use (about 92%).
Oestrogen side effects are potentially higher than in the low dose pill
The actual oestrogen dose over each cycle is about 50% higher than for a low dose pill and thus it is potentially associated with a higher risk of clotting, including clots in the legs, strokes and heart attacks. (This has not been shown clinically.)
Side effects are similar to those with the pill, although rash associated with the patch also occurs and is not uncommon (about 20%). The application site should be rotated to reduce rash incidence.
Obesity and the patch
Failure rate with the patch may be slightly higher in women weighing over 90kg.
The ‘Minipill’
The minipill is a contraceptive pill that contains a small amount of progestogen only. (There is no oestrogen.) It works by making the mucous at the top of the vagina and in the cervix thicker which stops sperm entering the uterus and in some women it also inhibits egg release.
It is not quite as effective as the COCP but has the advantage of being able to be used by women who can not take oestrogen. This includes;
- Women who are breast feeding (Breast feeding itself works as a contractive but not reliably.) This is its most common use.
- Women who have a history of high blood pressure or smoke heavily
- Women who have a history of clotting, stroke or heart attack.
Women who can not take the minipill include those with
- A past ectopic pregnancy. (The minipill increases the woman’s already elevated risk of this happening again.)
- A history of ovarian, cervical, uterine (womb) or breast cancer
- Undiagnosed abnormal or unusual bleeding from the vagina
Unlike the COCP, the minipill needs to be taken every day with no 7 day break once a month. Thus, there are no sugar tablets and all packs are 28 day packs. The pill is started on the first day of the menstrual period. If the women is breast feeding and not having periods then it can be started at any time. Maximum contraceptive protection takes about seven days.
Missing a minipill
If you miss a tablet, take one as soon as you remember and then go back on the once a day regimen. You will need some other form of contraception for at least three days and if you had sex around the time that you missed a tablet, see your doctor as emergency contraception may well be necessary.
Other times when the minipill may not work
There are several occasions when the minipill may not work even though it is taken correctly.
- The minipill needs to be absorbed in the intestines and if you have significant diarrhoea or vomiting, then some of the hormone may be vomited up or may pass through without being absorbed.
- Some medications interfere with the effectiveness of the hormone in the minipill. This issue needs to be discussed with your doctor. Some antibiotics are a common cause and natural therapies can also be a problem.
During these times, other contraceptive measures need to be taken and continued for seven days after the problem has gone (or the other medication ceased). Again, if they occur during the early stages of a minipill pack and you have had vaginal sex recently, the need for emergency contraception should be considered.
Very uncommonly, the progesterone causes affects other parts of the body, causing symptoms such as vaginal dryness, flushing, headaches, nausea, acne, and mood. (The use of progestogens may be contraindicated in women with depression.)
Menstrual periods and the minpill
Menstrual periods vary considerably on the minipill. Some women have normal periods, others have none and others have irregular periods. This can make it difficult to tell whether you may have become pregnant and thus if you feel pregnant on the minipill, see your doctor to have a pregnancy test done. Slight spotting between periods also occurs commonly with the minipill.
Ectopic pregnancy (pregnancy outside the uterus, usually in the tubes) is slightly more common in women taking the minipill. This is a dangerous condition and is another reason why you need to see your doctor if you feel are pregnant.
Contraception while breast feedingBreast feeding itself does usually stop periods and works reasonably as a contraceptive. (During the first six months it has a success rate of about 98% as long as the baby is being exclusively breast fed and periods have not recommenced. However, this is often a time that women definitely do not want to become pregnant and for these women it is often best to use another form of contraception. Pills containing oestrogen are not useful as they will cause milk flow to stop and most women opt for a progesterone only pill, the minipill, which is discussed above. A very small amount the progesterone does enter the breast milk and will thus be consumed by the baby. It is very unlikely that tis would cause the baby any problems at the time of consumption or in the future but this aspect of the minipill has not been formally studied. There are other ways of delivering progesterone only contraception, including Depo Provera (long acting) injections and the Implanon rod that is inserted under the skin. The effects of progesterone ingestion by babies, via the use of Depo Provera as a contraceptive for their breast feeding mothers, has been studied well studied and has not shown any adverse side effect on the babies at the time of ingestion or later in life. While it may be reasonable to extrapolate these results to other forms of progesterone-only contraception, approval for their use in breast feeding women has not been formally given in Australia. Despite this, as stated above, the contraceptive most commonly used by breast feeding women in Australia is the minipill. |
Progestogen implants (inserted under skin) 'Implanon'
Implanon is a small rod containing a progestogen that is inserted under the skin, usually on the inside of the non-dominant upper arm, where it can provide contraception for up to three years. This process is done under local anaesthetic and is thus not painful or only slightly uncomfortable. It should not be left in longer than three years. It is very effective with a failure rate of less than 1% and it very easy to use. It is particularly useful in women who can not take oestrogen or who have problems with COCP intestinal absorption (e.g. inflammatory bowel disease.) and in women who have persistent problems with forgetting to take oral contraceptives.
The main problem is irregular periods, which is relatively common. Periods can vary from no bleeding at all to frequent irregular bleeding that causes considerable inconvenience. Other side effects include headaches, weight gain and breast tenderness.
However, it is the irregular bleeding that principally leads to about 25% of users opting for early removal if the implant. Other relatively uncommon side effects include skin problems (acne), weight gain, breast tenderness and mood changes. (The use of progestogens may be contraindicated in women with depression.)
It works by inhibiting egg release and by keeping the lining of the uterus thin so that fertilised eggs can not grow there. As with the minpill, it can be used in women who can not take oestrogen or who experience unacceptable oestrogen side effects.
Contraindications include a past history of breast cancer (especially if diagnosed within the last five years), a current clot (deep venous thrombosis) or clot in the lung (pulmonary embolus), undiagnosed abnormal vaginal bleeding, active viral liver disease (hepatitis) and use with drugs affecting the liver.
As with all forms of hormonal based contraception that only uses progesteron, it is quickly reversed (within a week or two) once administration ceases; in this case with the removal of the implant. Again, this is usually quite a simple, non-painful process.
Intrauterine devices (IUDs)
There are two types of IUD
- The copper IUD
- The progestogen containing IUD
IUDs are a very effective, cheap and long-lasting form of contraception. It is most suitable for women in a stable long term relationship who wish a break of at least two years between children or women who wish longstanding contraception following completion of their family but who do not wish to opt for sterilisation.
They are generally not suitable for women who have not a baby as they are more difficult to insert and are also not suitable for women who are not yet in a stable relationship due to the increased risk of infection. For these reasons they are rarely prescribed for young women.
Insertion
IUDs are inserted by medical practitioners. Two appointments are required, the first to do an gynaecological examination, including a Pap smear, and take tests to exclude any current vaginal / pelvic infection and the second to insert the IUD. Period-like cramps and bleeding or spotting are common in the first few days after the IUD is inserted. Any worse symptoms should be reported to your doctor. Vaginal sex should be avoided for two to three days after insertion. The IUD should be checked by your doctor about six weeks after insertion.
Complications
There are also a couple of problems associated with their use
- Infection: The main problem is that they increase the risk of pelvic infections occurring, most commonly chlamydia. While these can be treated fairly easily, the residual scarring around the tubes can cause long-term infertility problems and thus this is a major reason that IUDs are generally not suitable for women who have not had children. Any women with an IUD who experiences symptoms of a pelvic infection, most commonly vaginal discharge and pelvic pain, needs to seek medical treatment promptly. If either partner has casual sex or if the woman with the IUD has a new partner, then condoms should be used till both partners are tested to make sure they do not have any sexually transmitted diseases. It is worth noting that some recent evidence suggests that this risk has been overestimated and that it is mostly a problem in the first few weeks after insertion.
- Ectopic pregnancy: There is a slight increase in the risk of ectopic pregnancy (that is pregnancy outside the uterus or womb, usually in the tubes) which is a serious condition. This risk is less with the progesterone IUD.
- Menstrual periods are often longer and heavier and more painful: This means that they are often not a good choice for women who already have ‘difficult’ periods
- Becoming pregnant with an IUD in place: Removal of the IUD in these circumstances is associated with a 30% risk of miscarriage. Any woman with an IUD in place who misses a menstrual period needs to see a doctor for a check up and pregnancy test.
- Dislodging or expulsion of the IUD: Occasionally the IUD can be expelled, often with periods or when straining to pass a bowel motion, and this may not be noticed by the woman. Obviously this can lead to pregnancy. (This most commonly occurs within the first few weeks after insertion.) It can dislodge higher into the uterus or rarely into the uterine wall. In this case it may not be possible to remove it and surgical removal may be required. This is usually easy but certainly a hassle. Women with IUDs should check that they are still in place after the end of each menstrual period. This can be done by inserting fingers high into the vagina to feel for the presence of the small nylon string that is attached to the end of the IUD and that protrudes through the cervix into the vagina. If it is not felt it is important to see your doctor immediately to find out whether it is still in the uterus.
IUDs are not suitable for women who
- may be pregnant
- are at increased risk of developing pelvic infections including those who
- have more than one sexual partner
- have a partner who has more than one sexual partner
- have recently changed sexual partners.
- have a current vaginal or pelvic infection (PID, infection in the tubes).
- have had more than one pelvic infection in the past.
- have a medical condition that makes it very risky to develop an internal infection, e.g. rheumatic heart disease or be treated with steroids or other drugs that stop the immune system from working properly.
- have abnormal bleeding from their vagina, the cause of which has not been diagnosed
- have fibroids or other conditions that change the shape of the uterus or cervix.
- have an abnormal Pap test which is being investigated
- have any signs of genital cancer.
IUDs are also less suitable for women who have problems with anaemia or who have had an ectopic pregnancy in the past or who, as stated above, have not had a baby.
Menstrual periods and IUDs
Copper IUDs cause menstrual periods to be heavier, longer and more painful. This means that they are often not a good choice for women who already have ‘difficult’ periods.
On the other hand, Progesteron IUDs actually decrease bleeding and pain associated with menstrual periods.
The Progesteron IUD (‘Mirena’)
This is a small ‘T’ shaped device that has a cylinder containing progesterone around its stem. It works by preventing the normal thickening in the lining of the uterus that occurs in the later half of each menstrual cycle and this prevents implantation and growth of fertilised eggs. It also causes a thickening of vaginal mucous that helps prevent sperm entering the uterus and in the first year of use can inhibit egg release.
It causes irregularity in menstrual periods in the first four to six months, which usually then settles leading to regular period bleeding that is considerably lighter than normal. (The reduction in menstrual blood loss can be as high as 90%.) This is a considerable advantage for women in their forties who often have heavier periods. Use in the United Kingdom had reduced the need for treatment of dysfunctional (heavy) bleeding by hysterectomy in this age group by about 40%.
It is also a good option for women over 35 who smoke or have other risk factors for vascular disease. Recent use has also shown that it can be considered for use in younger women and in women who have not had a baby, although it does increase the risk of pelvic infections and should not be used where a current pelvic infection is present. (Thus, in these women tests for pelvic infection should be done prior to insertion.) Women with a past history of pelvic infection should consider other contraceptive options.
Very uncommonly, the progesterone causes affects other parts of the body, causing symptoms such as vaginal dryness, flushing, headaches, nausea, acne, and mood. (The use of progestogens may be contraindicated in women with depression.)
Progesteron IUDs can be left in place for up to five years.
The copper IUD
The copper IUD is a small plastic device in the shape of a ‘7’ with a copper wire wrapped around its stem. It is inserted into the uterus by a medical practitioner and a single device can provide effective contraception for five to ten years.
No one is sure exactly how they work, although it is known that it affects sperm mobility and thus egg fertilisation.
The device has a fine nylon string attached to its base that projects through the cervix into the top of the vagina. Pulling this string enables the device to be easily removed and it can easily seen by your doctor during a gynaecological examination or felt (high in the vagina by finger examination) which provides proof that the device is in its correct position.
It is most suitable for women who wish a break of at least two years between children or women who wish longstanding contraception following completion of their family but who do not wish to opt for sterilisation.
Barrier methods of contraception
Male condoms
Male condoms are used during sexual intercourse for two reasons.
Contraception: In general condoms are not as effective as the pill and IUDs as a method of contraception, with typical use providing about 85% protection. As a contraceptive, they are most appropriately used when the woman has irregular, very infrequent sex and the woman does not wish to take another form of contraception or when an additional form of contraception is needed to that being presently used. The main problem is that it needs to be used properly to be effective and this ‘proper use’ needs to occur while intercourse is happening. This is not always a time that couples are thinking clearly, especially if alcohol has been consumed. It needs to be stressed that the woman needs to be confident that she will be able to use them properly if condoms are to be relied on as a sole form of contraception. It is important that condoms are used every time as pregnancy can occur even with sexual intercourse during menstruation.
Prevention of sexually transmitted diseases: Condoms should be used by EVERY couple having sexual intercourse when they are not in a longstanding relationship to prevent sexually transmitted diseases. They are your best protection. It is important to stress that a longstanding relationship does not mean someone who you have been having sex with for a month or two. It means a relationship that you are perhaps considering making a permanent one. Before ceasing condom use, it is wise for both partners to be tested for sexually transmitted diseases so that such disease is not later spread between partners. You may think that such disease is uncommon and your risk of infection is low. However some diseases such as Chlamydia are relatively common in both males and females (See section on Chlamydia.) and others are life-threatening, such as HIV/AIDS. It is not a matter to trifle with.
Types of male condoms
There are two types of male condoms, plastic and rubber. Both are effective as long as they are used properly although the plastic one is thinner and stronger.
Condom use
Condoms should be used only once. They are perishable and thus should be stored in a cool place and used before their expiry date.
After applying the condom to the erect penis, it is important to apply some lubricant to the outside of the condom to help make sure that it does not rupture. Water based lubricants are suitable for both types of condom but oil based lubricants, such as petroleum jelly or massage oil, should NOT be used on rubber condoms as they may cause them to rupture.
After intercourse the penis should be removed while it is still erect and the condom should then be removed and then, after tying a knot at the end, discarded in the rubbish bin; not down the toilet. If the penis becomes flaccid in the vagina then there is a risk that semen will leak out and enter the vulva / vagina.
If a male condom perforates during use, emergency contraception may be necessary and needs to be discussed the following day with your doctor.
Female condoms
There are also female condoms which also are effective as a means of contraception and in preventing sexually transmitted diseases.
It is made of soft plastic and fits into the vagina. It is approximately 17cm long and has a flexible ring at each end and tends to have a more natural feel than a male condom; something that both men and women prefer. Importantly for women, it gives them control over contraception, which is much less the case with male condoms. As the female condom covers some of the vulva, it may provide better protection against sexually transmitted infections, such as herpes simplex and human papilloma-virus infection, than male condoms.
It can take some practice to use and the woman may want to try insertion one several times before using it during intercourse.
The female condom can be inserted before having actual sex and obviously does not require an erect penis. They allow lubrication. Like male condoms, they should only be used once.
If a female condom perforates during use, emergency contraception may be necessary and needs to be discussed the following day with your doctor.
Diaphragms
Diaphragms are occasionally used as a contraceptive device but are usually not the best choice for several reasons.
Firstly, they work primarily as barrier method of contraception, unlike condoms they do not protect against sexually transmitted diseases. Thus they are not useful for women who are not in a long term relationship unless condoms are used as well.
Secondly, they do not give very good contraceptive protection, with typical use only providing about 84% protection. Thus, they are not very good for women who are having regular sex in a long term relationship.
Emergency contraception – Reassurance if you are uncertain.
Usually a woman is aware that she is not covered regarding contraception when she has had sexual intercourse. This opportunity to prevent unplanned pregnancy should not be ignored with the hope that all will be well. Emergency contraception is freely available in Australia from pharmacies and a doctors prescription is not needed. It works for up to five days following the unprotected sexual intercourse and has almost no side effects. (It is NOT just a morning after pill.)
What is emergency contraception?
Emergency contraception is basically a special dose of the hormone progesteron that a woman can take to reduce the chance of becoming pregnant following unprotected sexual intercourse. This includes rupture of condoms or taking the pill incorrectly as well as having intercourse without any contraception. It is important to realise that, while pregnancy is more likely when sex occurs at certain times during the menstrual cycle, a woman can become pregnant at almost any time, even when sex occurs during menstruation. Thus, emergency contraception needs to be considered any time unprotected intercourse occurs.
Emergency contraception comes pre-packaged and consists of two pills containing a large dose of a progestin hormone. There are two brands, Postinor-2 or Levonelle-2, and both are available over-the-counter from any pharmacy. It does not require a doctor’s prescription.
The two pills are usually taken by 12 hours apart, with the first one being taken as soon as possible after the unprotected sexual intercourse occurred. (Recent evidence has shown that taking both together is equally effective.) The closer emergency contraception is started to the episode of unprotected sexual intercourse the more effective it is. However it will work up until about 5 days after. Thus, the term ‘morning after pill’ that is commonly used to describe emergency contraception is quite misleading.
Emergency contraception works in two ways.
- In women who have not yet released an egg (ovulated) during the cycle, it acts to delay ovulation until after the sperm from the sexual contact has gone, thus preventing egg fertilisation.
- Where ovulation has already occurred, it is thought to act by prevent preventing the fertilised egg from implanting in the uterus.
Overall, it prevents about 87% of pregnancies; although if it is taken within 24 hours of intercourse, the success rate is around 99%. It causes few side effects, although irregular bleeding (often as spotting) can occur and about 2% of women will get some nausea. The menstrual period following taking emergency contraception should occur at the expected time and if it doesn’t or is delayed, a pregnancy test should be done. The woman should continue her usual form of contraception, including the COCP (the pill), during the cycle that the emergency contraception is taken in.
Most women can take emergency contraception safely, although prior medical advice should be sought if the woman has had a hormone-dependent cancer and it should not be taken when a woman is already pregnant. A very small amount of the medication (about 0.1%) will enter breast milk in lactating women. Some medications will also reduce its effectiveness. (Talk with your doctor.)
The cost is in the region of $20 to $30.
Medical practitioners can provide this form of medication from samples they have of the mini-pill, but the progesterone dose in the mini-pill is quite small and two doses of 25 tablets are required to replicate the dosage provided in the commercially available emergency contraception preparations.
Preventing unplanned teenage pregnancy - a parent perspective
By year 12 at school, about 50 per cent of males and females have had vaginal sex, and, not surprisingly, about 23 per cent of these teenagers reported that they had consumed excess alcohol at the time. Unplanned teenage pregnancy is a very important health issue in Australia with the potential to cause much long-term emotional suffering. Teenage women who choose to become parents with an unplanned pregnancy often suffer significantly from mental health problems, such as three times the usual incidence of post-natal depression, and social problems, such as reduced opportunities for education and work, and a reduced standard of living. They also have a higher pregnancy complication rate. On the other hand, those teenage women who choose to have their pregnancy terminated suffer emotional and mental health problems that can persist for years.
While no exact figures exist, it is estimated that about 80,000 abortions occur in Australia each year (about one in five of all pregnancies). The majority occur in young women, especially the early twenties age group. (64 per cent occur in women under thirty). Almost 20 per cent of Australian women will have an abortion at some stage in their lives.
About 20 per cent of Australian women will become pregnant in their teenage years, with the rate being about 44 per 1000 female teenagers per year, and slightly over 50 per cent end in termination. (Interestingly the overall termination rate in Australian women aged 15 to 44 years is not much lower, being about 20 per 1000 women per year.)
This teenage termination rate is the sixth highest amongst 'OECD countries' and does not compare favourably with many other developed countries. For example, the rates for German (5.3 per 1000) and Dutch (3.9 per 1000 per year) teenagers are less than a quarter of those for Australian teenagers (1996 figures). Of those teenagers giving birth in Australia, 90 per cent are unmarried and 60 per cent have no male partner.
As the decision to have an abortion is a difficult one for most women and one that often has long-lasting psychological repercussions, the above statistics represent a huge social and psychological problem facing Australian women.
With the above in mind, it is unfortunate but perhaps not surprising to realise that Australia, unlike many other developed countries, has no major teenage pregnancy prevention initiative. Part of the reason there is no sex education program lies in the belief that education increases the likelihood of permissiveness and earlier sexual activity. However, the opposite is in fact true.
The consequences of this lack of sex education are amply demonstrated by a study recently conducted in Perth that found only 10 per cent of 126 teenage mothers had become pregnant intentionally. Despite this, about 76 per cent were not using contraception at the time they became pregnant and 68 per cent had never spoken to a doctor about contraception.
In the Netherlands, sexual health education campaigns aimed at teenagers have greatly reduced teenage pregnancy and sexually transmitted disease rates and have resulted in roughly 80 per cent of Dutch teens using contraceptives during their first sexual intercourse. This is much higher than in Australia, where the rate is about 50 per cent.
Luckily the message is starting to get through in Australia, with the Victorian Government starting to formulate a ‘best-practice’ sex education program for schools. However, until such a coordinated program exists, it is up to individual families and schools to educate their teenagers regarding the risks of pregnancy. Do not pretend the traumas associated with teenage pregnancy will not affect your family.
“Contraceptives should be used on every conceivable occasion”
Spike Milligan (1918-2001)
There is insufficient room in this web site to provide extensive information regarding the many issues involved in pregnancy prevention. Details regarding this information can be sourced from your GP, your school or the resources listed below. The information provided to adolescents should include the following:
- Accurate information about the risks of not using contraception. Issues that need to be addressed include pregnancy and sexually transmitted diseases. It needs to be emphasized that protection against becoming pregnant is not enough. Unless the couple is in a long term relationship, barrier methods of contraception (usually condoms) need to be used with all intercourse to prevent infection with potentially dangerous diseases such as HIV/ AIDS, herpes, and chlamydia. One major problem is the definition of long term relationships, with many young couples giving up condom use after a sexual relationship lasting only three weeks. Before stopping barrier protection, partners should consider being screened for common diseases, such as chlamydia. To make the cost and inconvenience of such screening worthwhile, condom use for much longer than three weeks should be seriously considered.
- The provision of adequate access to contraception, especially condoms.
- Adequate education about how to use contraception. It is thought that up to 65 per cent of unintended pregnancies occur in women using contraception. Stressing the need to be compliant with taking oral contraceptives is very important component of this process. One study has shown that up to 45 percent of women miss at least one pill per month.
- Knowledge about emergency contraception. Emergency contraception is available in tablet form from pharmacies and when taken soon enough after unprotected intercourse (up to five days) will prevent pregnancy in most cases. (It is most effective when taken within three days of intercourse.) You can of course obtain emergency contraception from your doctor also and he or she will also be more than happy to discuss more permanent methods of contraception at the same time.
- Education about the issues involved in giving birth and bringing up children when young. This should include mention of the benefits of having a long-term partner to help with the child’s upbringing. Few teenagers have much idea of the difficulty and size of this task.
- Measures to reduce the incidence of unwanted sexual activity, such as refusal skills and skills to prevent date rape. This should include education about the association of alcohol and other drug use with unprotected sexual activity and later regretted sexual activity.
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Other sexual health information for parents and adolescents on this web site
Contraception for adolescents and teenagers There is a separate section in the web site that deals in detail with contraception options for adolescents and young adult women.
See section 'Contraception for adolescents and young women - preventing unwanted pregnancy'
Unplanned pregnancy - What are the options?
See section 'Unplanned pregnancy options'
Sexually transmitted diseases and their prevention
This focuses on Chlamydia and Genital Hepres, the two most common sexually transmitted diseases in young people. Other diseases such as HIV/AIDS are also covered.
See section 'Sexually Transmitted Diseases and their prevention'
Further information on parenting
Further reading regarding teenager sexual health
Sexwise by Dr Janet Hall. Published by Random House Australia.
(What every young person and parent should know about sex. Dr Hall empowers her readers by telling them the facts - and giving it to them straight.)
Unzipped by Bronwyn Donaghy. Published by Harper Collins
(A book that deals frankly and sympathetically with the crucial role that love and emotions play in every aspect of adolescent sexuality.)
Further titles regarding puberty and adolescent sexuality are available on the Children’s Hospital at Westmead web site. www.chw.edu.au/parents/books. (Both the above books are mentioned on this web site and are recommended by staff at this hospital.)
Some suggested books on parenting adolescents
What to do when your children turn into teenagers by Dr D. Bennett and Dr Leanne Rowe (This is a wonderful book that is unfortunately now out of print. Second hand copies may still be available.)
You can't make me by Dr D. Bennett and Dr Leanne Rowe
I just want you to be happy. Preventing and tackling teenage depression. by Professors Leanne Rowe, David Bennett and Bruce Tonge. Published by Allen and Uwin, 2009.
Puberty boy by Geoff Price
Puberty girl by Shushann Movsessian
The puberty book by Wendy Darvill and Kelsey Powell
Teen esteem by Dr P. Palmer and M. Froehner
Most children suffer anxieties at some time and another book (not on the above list) that is very useful for parents is - Helping your anxious child. A step by step guide for parents. by Rapee, R., Spence, S., Cobham, V. and Wignall, A.New Harbinger, 2000.
Further information on sexual health
Sexual health information
www.shinesa.org.au
Family Planning NSW
https://www.fpnsw.org.au
The Resource Center for Adolescent Pregnancy Prevention web site
(A good USA site that provides information and skills for both adolescents and for educators about preventing unwanted teenage pregnancies.)
www.etr.org/recapp