w w w . s e x u a l i t y a n d u . c a

w w w . s e x u a l i t ya n du. c a Choosing a contraception that’s right for u

s e x u a l i t y a n d u . c a Contents Female anatomyMale anatomy Female menstrual cycle Birth control options for men Male condom Birth control options for women Male sterilization Oral contraceptives Transdermal patchSTI prevention Vaginal ring Injectable contraceptiveSide-effects (hormonal contraception) Intrauterine system Myths and misconceptions Intrauterine device What to ask during your visit Female sterilization Female condom Diaphragm and cervical cap Sponge and spermicides

s e x u a l i t y a n d u . c a Unintended Pregnancies Unintended pregnancies with various contraceptive methods Numbers given are pregnancies for every 1000 women during first year of use Adapted from Trussell et al, 2004.

s e x u a l i t y a n d u . c a F e m a l e r ep r o d u c t i v e s y s t e m Fallopian tube Ovaries Uterus Cervix Vagina

s e x u a l i t y a n d u . c a F e m a l e r ep r o d u c t i v e s y s t e m Fallopian tube Ovary Uterus Bladder Clitoris Cervix Urethra Vagina Rectum

s e x u a l i t y a n d u . c a F e m a l e menstrual c y c l e

s e x u a l i t y a n d u . c a O r a l c o n t r a c e p t i v e s What are they? • Prescription tablets taken once a day • There are two main types: 1. Combination pill which contains two female hormones similar to the body’s own estrogen and progesterone 2. Progestin-only pill (or mini-pill) which does not contain estrogen • Available under a variety of brand names with various strengths and formulations How do they work? • Stop the release of a mature egg • Thicken the cervical mucus making it difficult for sperm to get to the egg • Change the lining of the uterus making implantation difficult Failure rate: 80 per 1000 women per year

s e x u a l i t y a n d u . c a O r a l c o n t r a c e p t i v e s What are the advantages? 1. One of the most effective reversible birth control methods when taken consistently and reliably 2. Simple and easy to use 3. Regulates menstrual cycle and reduces cramps 4. Does not interfere with intercourse 5. Decreases acne 6. Reduces the risks of endometrial and ovarian cancer 7. May reduce perimenopausal symptoms

s e x u a l i t y a n d u . c a O r a l c o n t r a c e p t i v e s What are the disadvantages? 1. Must be taken every day. The progestin-only pill must be taken at the same time every day 2. May cause irregular bleeding or spotting 3. Effectiveness may be reduced by other medications 4. Should not be used by women over the age of 35 who smoke 5. May increase the risk of blood clots, particularly in women who have certain blood disorders or a family history of blood clots 6. Does not protect against STIs 7. May increase the number of headaches 8. May not be suitable for breastfeeding women

s e x u a l i t y a n d u . c a T r a n s d e r m a l p a t c h What is it? • A patch that releases hormones through the skin • Can be placed on the buttocks, upper outer arms, lower abdomen, or upper torso excluding the breast • A new patch is applied once a week for three weeks followed by one week without a patch How does it work? • Prevents the ovary from releasing an egg • Thickens the cervical mucus making it difficult for sperm to get to the egg • Changes the lining of the uterus making implantation difficult Failure rate: 80 per 1000 women per year

s e x u a l i t y a n d u . c a T r a n s d e r m a l p a t c h What are the advantages? 1. A reversible and highly effective birth control method 2. Once-a-week regimen; no daily contraceptive routine required 3. Simple and easy to use 4. Regulates menstrual cycle and reduces cramps 5. Does not interfere with intercourse 6. Expected to provide other benefits similar to oral contraceptives; research is needed

s e x u a l i t y a n d u . c a T r a n s d e r m a l p a t c h What are the disadvantages? 1. May cause irregular bleeding or spotting 2. May cause breast sensitivity or headache 3. Does not protect against STIs 4. Patch may detach from skin (less than 2%) 5. Possible skin irritation at the application site

s e x u a l i t y a n d u . c a V a g i n a l r i n g What is it? • A flexible, nearly transparent ring that measures 54 mm (about 2 inches) across • The ring releases a continuous dose of hormones for three weeks while it is in the vagina How does it work? • Prevents the ovary from releasing an egg • Thickens the cervical mucus making it difficult for sperm to reach the egg • Changes the lining of the uterus making implantation difficult Failure rate: 80 per 1000 women per year

s e x u a l i t y a n d u . c a V a g i n a l r i n g What are the advantages? 1. A reversible and highly effective birth control method 2. Once-a-month regimen; no daily contraceptive routine required 3. Regulates menstrual cycles 4. Does not interfere with intercourse 5. Does not require daily attention 6. Expected to provide other benefits similar to oral contraceptives; research is needed

s e x u a l i t y a n d u . c a V a g i n a l r i n g What are the disadvantages? 1. Does not protect against STIs 2. May cause irregular bleeding or spotting 3. May cause side effects such as headache, nausea, or breast tenderness 4. May cause vaginal discomfort 5. The ring may be expelled from the vagina but this is uncommon

s e x u a l i t y a n d u . c a I n j e c t a b l e c o n t r a c e p t i v e What is it? • It contains a hormone called progesterone; it does not contain estrogen • The injection is given in the upper arm or buttocks every 12 to 13 weeks (four times a year) How does it work? • Prevents the ovary from releasing an egg • Thickens the cervical mucus making it difficult for sperm to get to the egg • Changes the lining of the uterus making implantation difficult Failure rate: 30 per 1000 women per year

s e x u a l i t y a n d u . c a I n j e c t a b l e c o n t r a c e p t i v e What are the advantages? 1. One of the most effective reversible birth control methods available 2. Does not contain estrogen 3. No daily contraceptive routine required; 1 injection lasts for 3 months 4. Effectiveness is not reduced by other common medications 5. May be suitable for breastfeeding women or women who smoke 6. With continued use, menstrual cycles cease in over half of users after the first year, and two-thirds of users after two years of use 7. Improves symptoms of endometriosis 8. Reduces the risk of endometrial cancer 9. Effective immediately when given during the first 5 days of a normal menstrual period

s e x u a l i t y a n d u . c a I n j e c t a b l e c o n t r a c e p t i v e What are the disadvantages? 1. Initially, irregular bleeding is the most common side effect 2. Decrease in bone mineral density which may be reversible when a woman stops taking the injection. Calcium supplementation is advised. 3. May be associated with weight gain in some women 4. Takes an average of nine months after the last injection for the ovaries to start releasing eggs again 5. Does not protect against STIs 6. The lack of a monthly period may be bothersome for some women

s e x u a l i t y a n d u . c a I n t r a u t e r i n e s y s t e m ( I U S ) What is it? • A T-shaped device that contains a hormone called levonorgestrel • The hormone is released slowly over time and acts on the lining of the uterus • It is inserted into the uterus by your physician in the doctor’s office • Two threads may be felt in the vagina, so a woman can check for herself to ensure that the IUS is still in place How does it work? • Thickens the cervical mucus making it difficult for sperm to reach the egg • Causes changes in the lining of the uterus that helps to prevent implantation • In some women, it may prevent the ovary from releasing an egg Failure rate: 1 per 1000 women per year

s e x u a l i t y a n d u . c a I n t r a u t e r i n e s y s t e m ( I U S ) What are the advantages? 1. Long-acting contraceptive; can be left in place for up to five years 2. No daily contraceptive routine required; device provides five years of contraception 3. Does not contain estrogen 4. Does not interfere with intercourse 5. Regulates menstrual cycle and reduces cramps 6. May be suitable for women who are breastfeeding 7. May reduce pain due to endometriosis 8. May lower the risk of precancerous cells developing in the lining of the uterus 9. Some users will stop having menstrual cycles during insertion period

s e x u a l i t y a n d u . c a I n t r a u t e r i n e s y s t e m ( I U S ) What are the disadvantages? 1. Possible side effects include irregular bleeding or spotting in the first months after insertion 2. Perforation of the uterus may occur at the time of insertion, but this is rare 3. May be expelled from the uterus, which happens with 6% of IUS users 4. Does not protect against STIs 5. Requires a physician for insertion and removal

s e x u a l i t y a n d u . c a Side-Effects of Hormonal Contraception Sideeffects that may occur during the first few months on hormonal contraception include : • irregular bleeding, spotting • nausea • mood swings • bloating • breast tenderness • headaches

s e x u a l i t y a n d u . c a Side-Effects of Hormonal Contraception Reason: • Your body is getting used to birth control • Fluctuating hormone levels when you start When will it stop? • Most symptoms are normal and will decrease or stop in the first 2-3 months. If they bother you or don’t get better: • Talk to your healthcare provider • There might be a method that’s better suited for you.

s e x u a l i t y a n d u . c a Myths and Misconceptions about Hormonal Contraception Common myths and misconceptions • Causes weight gain • Causes acne • Causes infertility • Causes birth defects • Should take a break from time to time • Smokers should not be taking it • Women over age 35 should not take the Pill • No need for condoms if you’re on the Pill

I n t r a u t e r i n e d e v i c e ( I U D ) s e x u a l i t y a n d u . c a What is it? • A T-shaped device with a copper wire around it • It is inserted into the uterus by a physician in the doctor’s office • Two threads may be felt in the vagina, so a woman can check for herself to ensure that the IUD is still in place How does it work? • Causes changes in the lining of the uterus • Prevents the sperm from fertilizing the egg • Decreases the ability of the sperm to penetrate the cervical mucus Failure rate: 8 per 1000 women per year

I n t r a u t e r i n e d e v i c e ( I U D ) s e x u a l i t y a n d u . c a What are the advantages? 1. Long-acting contraceptive; can be left in place for up to five years 2. No daily contraceptive routine required; device provides five years of contraception 3. Does not contain estrogen 4. Does not interfere with intercourse 5. May reduce the risk of endometrial cancer 6. May be suitable for women who are breastfeeding

I n t r a u t e r i n e d e v i c e ( I U D ) s e x u a l i t y a n d u . c a What are the disadvantages? 1. Possible side effects include irregular bleeding or spotting in the first months after insertion 2. Perforation of the uterus may occur at the time of insertion but this is rare 3. May increase menstrual bleeding or menstrual cramping 4. May be expelled from the uterus. This happens in 2–10% of IUD users 5. Does not protect against STIs

F e m a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a Sites ofSterilization Tubal occlusion “Having your tubes tied” What is it? • A surgical procedure to close or block the fallopian tubes • Techniques include: • Laparoscopy – special instruments are inserted through two tiny incisions (less than 1 cm long) in the abdomen • Mini-laparotomy – also requires a small cut in the abdomen • Hysteroscopy – use of a thin telescope inserted into the uterus • Fallopian tubes may be blocked by using one of the following: • A clip or a ring • Cautery (an electric current) • Removing a small piece of each tube • Hysteroscopy for the insertion of tubal plugs (Essure) How does it work? • The fallopian tube is blocked and therefore the sperm and egg cannot meet Failure rate: 5 per 1000 women per year Ligation Clips Essure Cauterization

F e m a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a What are the advantages? 1. No daily contraceptive routine required; nothing to remember 2. Private 3. Does not interfere with intercourse 4. No significant long term side effects

F e m a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a What are the disadvantages? 1. Usually permanent and difficult to have reversed 2. Possible post-sterilization regret 3. Possible short-term surgery-related complications: abdominal discomfort; bruising, bleeding, or infection at the incision site; reaction to anesthesia 4. If pregnancy occurs, there is a higher chance that it will be an ectopic pregnancy 5. Does not protect against STIs

F e m a l e c o n d o m s e x u a l i t y a n d u . c a What is it? • Soft, disposable, polyurethane sheath • Available in drugstores without a prescription How does it work? • Placed in the vagina before intercourse • Lines the vagina completely, preventing direct contact between the penis and the vagina and preventing the exchange of body fluids • Sperm is trapped in the condom, which is thrown away after intercourse • A new condom should be used for each repeated act of intercourse Failure rate: 210 per 1000 women per year

F e m a l e c o n d o m s e x u a l i t y a n d u . c a What are the advantages? 1. Available widely without a prescription 2. No daily contraceptive routine or continued use required 3. Woman remains in charge of placement and use 4. Protects against some STIs

F e m a l e c o n d o m s e x u a l i t y a n d u . c a What are the disadvantages? 1. Must be available at time of intercourse 2. Requires proper insertion technique 3. Flexible inner ring may cause discomfort for some 4. More expensive than the male condom and not available in all stores 5. Makes a noise during intercourse 6. May slip or break during intercourse 7. May be considered messy by some

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a Diaphragm and Cervical Cap What are they? • Intravaginal barrier methods that are used together with a spermicide • The diaphragm is a latex dome with a flexible steel ring around its edge (a non-latex diaphragm is also available) • The cervical cap is thimble-shaped silicone cap • Positioned into the vagina (diaphragm) or over the cervix (cervical cap) before intercourse • Must be left in the vagina for 6–8 hours after intercourse How do they work? • A pelvic examination by a qualified health care professional is required for fitting diaphragms and cervical caps • Inserted into the vagina and fit over the cervix • When positioned properly, they block the entry to the uterus so sperm cannot enter and fertilize the egg • Spermicide should be reapplied for each repeated act of intercourse Failure rate: 160-320 per 1000 women per year Cervical Cap Diaphragm

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the advantages? 1. Does not contain hormones 2. Can be used by women who are breastfeeding 3. Some protection against certain STIs

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the disadvantages? 1. Must be available at time of intercourse 2. Requires proper insertion technique 3. Does not protect against certain STIs 4. Cannot be used by people who are allergic to spermicides 5. Diaphragm may increase the risk of persistent urinary tract infection 6. Cervical cap should not be used during menstruation 7. May become dislodged during intercourse 8. Cervical cap may cause vaginal odour and discharge

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a Sponge and Spermicides What are they? • The sponge is a soft, disposable, polyurethane foam device impregnated with a spermicide • Spermicides disable sperm and come in several forms, including creams, jellies, tablets, suppositories, foams, and film How do they work? Sponge • Fits over the cervix • Traps and absorbs sperm to augment effect of spermicide • Spermicide in the sponge disables the sperm • Effective for up to 12 hours Spermicides • Contain an ingredient that disables sperm • Should be used together with another form of contraception Failure rate: 160-320 per 1000 women per year

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the advantages? 1. Does not contain hormones 2. Can be used by women who are breastfeeding 3. Can be used by women who smoke 4. Spermicide may provide added lubrication

F e m a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the disadvantages? 1. Must be available at time of intercourse 2. Does not protect against certain STIs 3. Cannot be used by people who are allergic to spermicides 4. Requires proper insertion technique 5. Sponge users may experience vaginal irritation or infection 6. Spermicide must be inserted into the vagina in advance (time depends on product) 7. If left in the vagina in excess of the recommended time, symptoms of toxic shock syndrome may appear

s e x u a l i t y a n d u . c a M a l e r ep r o d u c t i v e s y s t e m Seminal vesicles Vas deferens Prostate gland Penis Epididymis Testicle

M a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a Male Condom What is it? • A soft disposable sheath • Available in various shapes, sizes, thicknesses, colours and flavours • Most are latex, but non-latex condoms are also available in polyurethane, silicone, and lambskin How does it work? • Fits over the erect penis • Acts as a physical barrier preventing direct genital contact and the exchange of genital fluids, so the sperm does not enter the uterus and fertilize the egg • A new condom is used for each repeated act of intercourse Failure rate: 150 per 1000 women per year

M a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the advantages? 1. Available widely without a prescription 2. Inexpensive 3. Latex condoms protect against STIs 4. Allows the male partner to assume some responsibility for birth control 5. Both partners can participate in their use 6. May help the wearer avoid premature ejaculation

M a l e b a r r i e r m e t h o d s s e x u a l i t y a n d u . c a What are the disadvantages? 1. Must be available at time of intercourse 2. May slip or break during intercourse 3. Must be stored and handled properly 4. People with latex allergies cannot use latex condoms, but may be able to use non-latex condoms 5. May reduce sensitivity for either partner 6. May interfere with the maintenance of an erection 7. May reduce spontaneity 8. Lambskin condoms do not protect against STIs

M a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a Vasectomy What is it? • A surgical procedure to close or block the vas deferens (the tubes that carry sperm to the penis) How does it work? • The vas deferens are closed so that no sperm is released to fertilize the egg • Common techniques include: • Conventional vasectomy – one or two incision are made in the scrotum to reach the vas deferens • No-scalpel vasectomy – a puncture opening is made in the scrotum • Vas deferens are closed by: • Electric current (cauterization) • A mechanical method, such as a clip • Removal of a small segment of each tube • Another form of contraception is required until a semen analysis shows no sperm Failure rate: 1.5 per 1000 women per year Vas deferens Urethra Site of Vasectomy

M a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a What are the advantages? 1. No contraceptive routine required; nothing to remember 2. Private 3. Does not interfere with intercourse 4. No significant long-term side effects 5. Simple procedure 6. Less invasive and more cost-effective than tubal ligation for women 7. Allows the male partner to assume some responsibility for birth control

M a l e s t e r i l i z a t i o n s e x u a l i t y a n d u . c a What are the disadvantages? 1. Difficult to have reversed 2. Possible post-sterilization regret 3. Possible short-term surgery-related complications: pain and swelling; vasovagal reaction; infection at the incision site 4. Does not protect against STIs 5. Not effective immediately. Must do a follow-up sperm analysis that shows no sperm are present in the semen

S T I p r e v e n t i o n s e x u a l i t y a n d u . c a Dental dams and gloves A dental dam is a small piece of latex similar to the material used for latex condoms. • It can be used during oral sex. The dental dam is stretched across a woman’s vagina to prevent the exchange of bodily fluids. • It can also be used in other activities where a barrier is desired. • Latex surgical gloves can also be used in activities where a barrier is desired. General tips • When using latex dental dams, gloves, or condoms, apply only water- based lubricants. They are available at drugstores. • Use new dental dams, gloves, or condoms for each partner. • Do not re-use latex barriers or turn them over and use the other side.

S T I p r e v e n t i o n s e x u a l i t y a n d u . c a 1 Cutting a condom to make a dental dam • When a dental dam is not available, a latex condom can be cut to create a latex barrier. 1. Unroll a new condom. 2. Using scissors, cut off both ends of the condom, removing the closed tip and the round loop at the base. 3. Cut the condom lengthwise so that it opens up into a rectangle. • If you are going to use the barrier for oral sex, you may wish to select a condom without spermicide or lubrication. A flavoured condom may be a good choice. 2 3

S T I p r e v e n t i o n s e x u a l i t y a n d u . c a * Remember that no method of protection from STIs is perfect. Some STIs can be passed through skin-to-skin contact.

s e x u a l i t y a n d u . c a What To Ask Your Healthcare Provider Following are some questions you might want to ask regarding your sexual health. A good idea is to make a list before you visit. Birth control related: • How do I know what birth control method is best for me? • How to take your method • How to deal with missed pills, patches, rings, or injections • What are the side-effects? Which are normal and how can I cope with them. General women’s health • Should I get a mammogram? How do I know if I'm doing my breast self-exam correctly? • How often do I need a Pap smear or gynecological check-up? • How do I know if my period is normal? • Should I be tested for AIDS or other STIs?

w w w . s e x u a l i t y a n d u . c a