March 8 is International Women’s Day, a time to celebrate the achievements of women and renew the pursuit of gender equality.
It’s also a good time to focus on sexual and reproductive health which is connected to many human rights, including the right to health, the right to education and the right to non-discrimination. The Canadian government and several international bodies such as the United Nations recognize that sexual and reproductive health and rights are essential to gender equality.
Contraception is one important component of sexual and reproductive health — and the options have come a long way since the pill, whether the ring, the patch or implants. Dr. Sharon Domb, a physician with Sunnybrook’s Department of Family and Community Medicine, walks through some of the alternatives people can choose from.
The birth control pill was first approved in Canada in 1960. Is it still a common form of contraception that patients often ask for?
It’s still a very commonly used form of contraception. Absolutely, patients often ask for it.
There’s also a birth control shot. How does that work?
Some kinds of hormonal contraception have two hormones: progesterone and estrogen. And some have just progesterone.
The birth control shot is just progesterone with long-term release. You have to get a new shot roughly every 12-13 weeks. It has to be prescribed by a physician or a nurse practitioner, but it can be injected by a nurse or other health-care provider.
Then there are methods like the vaginal ring or the patch. Can you explain how those compare?
I generally try to categorize contraceptive options into hormonal and non-hormonal methods.
Some people will say you know what, I don’t want anything with hormones and prefer to use some kind of barrier method instead.
When we talk about hormonal methods, there are various ways in which you can get hormones into your body. The combination estrogen and progesterone options generally work in the same way to suppress ovulation.
The main combined hormonal methods that have both estrogen and progesterone are: the pill, the patch and the ring.
With the pill you need to take it every day pretty much at the same time.
The patch is like a sticker that you stick on your body. You have to change it once a week. You do one patch each week for three weeks, and then for the fourth week you don’t have a patch and that’s normally when you would get your period.
The vaginal ring you put high up in your vagina. It stays in for three weeks and then you take it off for the fourth week and that’s when you get your period.
Other than the birth control shot, what are the hormonal methods with just progesterone?
The progesterone-containing IUD (intrauterine device) and the implant.
The implant that is available in Canada is Nexplanon. It’s inserted into your arm through a little surgical procedure. You can leave it there for up to three years.
The contraceptive implant is a relatively new method — it was approved in Canada in 2020 — and as you said, it’s longer lasting. Why might that appeal to some people?
When you look at what appeals to people, part of it is whether someone wants to think of their contraception every day and can remember to use it every day.
A lot of people find the pill easy to use because you don’t have to do anything surgical. But you’ve got to remember to take it. And there are lots of ways to remind yourself — there are different apps you can use, or you can set your alarm on your phone or stick it by your toothbrush. But some people still struggle with actually remembering to take it every day.
If you want something you don’t have to think about there is the implant or an IUD because those last years at a time.
There are so many options out there and each one has pros and cons in terms of effectiveness, possible health impacts and convenience. How should people decide which method is best for them?
I usually go through the basics with people to better understand what they’re looking for and then refer them to the Society of Obstetricians and Gynaecologists of Canada website if they want further information before making a decision. It goes through details in lay terms of the pros and cons of each one, how you use them, the effectiveness rates, which things you need a prescription for and which things you can get over the counter.
How does access fit into the equation? Are all of these methods equally accessible to patients who want or need them?
No. And it depends on what you mean by access. There’s access in terms of can somebody get in to see a physician? And there’s access in terms of financial means or whether somebody has health insurance coverage.
For any of the hormonal contraception methods you do need to see a physician or a nurse practitioner to get them because there are some considerations that need to be thought about in terms of whether or not the risks are warranted.
If you are talking about some of the barrier methods or spermicide, you don’t need to see a physician. Those are available at the pharmacy with no prescription.
We’ve got a lot of people who don’t have a family physician right now but there are still ways to access health care. If you need it, there are family planning clinics and walk-in clinics so there are ways to access the health-care system and contraception that way.
In terms of ability to afford contraceptives, some can be quite expensive, especially for those without private insurance coverage for medications. Prescription options are generally covered for patients under 25 in Ontario who do not have private insurance coverage. If finances are a concern, speak to your healthcare provider, as they may be able to recommend lower cost options or refer you somewhere that provides contraceptives at a discount.
When is the best time for people to talk to their doctor about sexual and reproductive health?
Ideally before they are sexually active to make sure they are paying attention to both contraception and STI (sexually transmitted infections) prevention.
We haven’t touched on emergency contraception. What should people know about that?
If you do end up in a situation where you’ve had intercourse without protection and you are concerned about being pregnant, there is something called Plan B (and there are other brands too). That can be obtained at the pharmacy without a prescription, ideally within 24 hours but it’s okay in the first five days after unprotected sex. It decreases the risk of pregnancy by about 80 percent.
If you are past that five-day window you can also have an IUD inserted by a health-care provider and that is quite effective if done within the first week.