Top things to know
Some non-hormonal birth control options require your attention every time you have sex, while others last for years or are even permanent
Hormonal birth control is safe for most people, but may not be a good option if you have heart disease, recently birthed, or don’t like how it makes you feel
Condoms are affordable, accessible and protect against pregnancy and sexually transmitted infections (STIs)
Fertility awareness-based methods (FABMs) may be a good option for you if you want to avoid hormones and learn more about how your reproductive system works.
Mobile period tracking apps can be an effective form of birth control if you choose one that is approved or cleared by the FDA
There are about 922 million women and people with cycles worldwide aged 15-49 that use some kind of birth control (1). This includes both hormonal and non-hormonal birth control methods. In the USA, 99% of people with cycles have used at least one type of birth control method and 88% have used a birth control pill, injection, patch, or intrauterine device (IUD) at least one time (2).
In the USA, most people with cycles will use three different birth control methods, and 30% will use five or more (2). Hormonal birth control is not ideal for everyone though. Some people can not use certain methods of birth control because of a health condition like heart disease or life stage like the first weeks postpartum (3, 4). Other people may have personal reasons for wanting to avoid hormonal birth control. If you’re exploring your options, there are a few hormone-free options to learn about.
Non-hormonal birth control options and their effectiveness in preventing pregnancy
There are 12 non-hormonal birth control methods. Each one has its own pros and cons. When choosing a birth control method, consider your main goal (preventing pregnancy or something else) and how comfortable you are with the possibility of becoming pregnant if the method you choose doesn’t work.
The following sections discuss each non-hormonal birth control method in detail, as well as each method's unintended pregnancy rates. “Typical use” describes using a method like an average person does. That means there may be times when a person does not use their birth control method or uses it incorrectly. “Perfect use” describes using a method exactly as directed with every single sexual encounter.
1. Non-penetrative sex
Unintended pregnancy in one year of use:
Typical use: In the moment of intimacy, non-penatrative sex can “accidently” lead to penatrative sex. Pregnancy or STIs can happen if another form of birth control is not used (5).
Perfect use: Non-penatrative sex prevents pregnancy and STIs if fluids from one person’s body do not touch the other person (5).
Non-penetrative sex (noncoital sex or outercourse) is sexual activity that does not involve inserting anything into the vagina, anus, or mouth (5). This can include kissing, hugging, handjobs, dry humping, masturbating with a partner, using vibrators or toys, watching porn with a partner, massage, and breast play.
For some people, these activities can bring just as much sexual pleasure as intercourse.
2. External “male” condoms
Unintended pregnancy in one year of use: 13% (13 out of 100) typical use, 2% (2 out of 100) perfect use (5).
External condoms are barrier methods that protect against pregnancy and the spread of STIs if used as directed every single time (6). They are easy to find and affordable or free, making them the preferred birth control option for many people. Today, condoms come in a wide variety of styles, shapes, colors, and even flavors (5). Adding lubrication (lube) can help make sex with a condom more enjoyable. It is especially needed during anal sex to prevent the condom from breaking (8).
Types of external condoms
Latex: The most common. Only water or silicone-based lubricants can be used with latex condoms (5).
Plastic (Polyurethane): May be useful for those with allergies and can be used with oil-based lubes (5).
Lambskin: May be useful for those with latex allergies. They do not protect against STIs because of tiny pores that could allow viruses to pass through (6). You can use any type of lubrication with these condoms (6).
3. Internal “female” condom
Unintended pregnancy in one year of use: 21% (21 out of 100) typical use, 5% (6 out of 100) perfect use (5).
The internal or “female” condom is a barrier method that is typically less effective than the external condom but is still the right choice for some people. The internal or “female” condom is made of special plastics (polyurethane or nitrile) and placed inside the vagina or anus during intercourse (5). It has a ring on either end of the condom to hold it in place and prevent it from sliding too far into the vagina, which can increase the chance of pregnancy (5). It can be placed up to eight hours before having sex (6).
4. Diaphragm and cervical cap
Unintended pregnancy in one year of use: 17% (17 out of 100) typical use, 16% (16 out of 100) perfect use (includes the use of spermicide) (5).
Diaphragms and cervical caps are barrier methods that are both placed over the cervix (the opening of the uterus from the vagina) and used with spermicide (5). Cervical caps are smaller than diaphragms and fit tightly around the cervix (5). Diaphragms stay in place by sitting behind the pubic bone (5). Diaphragms and cervical caps do not protect against STIs (5). Both are available in the USA with a prescription.
An OBGYN, nurse practitioner, doctor or midwife puts the diaphragm or cervical cap in the first time to pick the right size. The healthcare provider inserts the index and middle finger into the vagina to feel where the device sits (5). Only use water-based spermicides or lubricants when using a diaphragm and a cervical cap (5, 8). Oil-based products can cause a cervical cap or diaphragm to break down (5, 8).
There is also a one-size-fits-all diaphragm, Caya (8). A healthcare provider may have you insert Caya during the visit and then perform a pelvic exam to make sure that it was placed in the right position (8). Water-based spermicide should also be used with Caya (8).
Unintended pregnancy in one year of use:
Typical use: 14% (14 out of 100) for those never pregnant; 27% (27 out of 100) for those who have previously been pregnant for at least 22 weeks (5).
Perfect use: 9% (9 out of 100) for those never pregnant; 20% (20 out of 100) for those who have previously been pregnant for at least 22 weeks (5)
The contraceptive sponge is a barrier method that is filled with spermicide and placed in the vagina before sex. It must be left in place for 6 hours after sexual activity to be effective (5). The sponge is available over the counter but is not as effective as the diaphragm (5). It can be used along with condoms and may be the right choice for some people, especially because it is easily accessible.
6. Creams, foams, and suppositories
Unintended pregnancy in one year of use: 21% (21 out of 100) typical use, 16% (16 out of 100) perfect use (5).
Spermicides are barrier methods that are often used with condoms, the cervical cap, and/or the diaphragm to make them more effective (6). They are available as small solid capsules called suppositories, foams, or creams (6). Apply spermicide close to the cervix. Do this by inserting the applicator, suppository, or cream into the vagina as far as you can (6). Spermicides slow down sperm and stop them from entering the cervix (5).
7. Phexxi (EVO100)
Unintended pregnancy in one year of use: 14% (14 out of 100) typical use, 7% (7 out of 100) perfect use (9).
Phexxi is not a spermicide. It is a non-hormonal vaginal gel barrier method that can be used without a condom (9). To use, put Phexxi into the vagina immediately before or up to 1 hour before sex using the applicator (9, 10). It will make the vagina a lower pH or more acidic (8). This makes it difficult for sperm to move (9).
In a study, some people who used Phexxi experienced vaginal burning and itching, yeast infections, or urinary tract infections (UTIs), but most people didn’t (10). Since the chance of UTIs might increase on Phexxi, talk to your healthcare provider before using Phexxi if you’ve had multiple (UTIs) or other urinary tract conditions (10). In the trial study of Phexxi fewer than 1% of people experienced any urinary tract infections; of this 1%, only one person had a serious infection (10).
8. Breastfeeding/chest feeding (lactational amenorrhea)
Unintended pregnancy in one year of use:
There isn’t an exact typical use number for lactational amenorrhea (LAM). One study looked at women who returned to work postpartum and were not able to breastfeed their infants on demand. It found the rate of unintended pregnancy increased to around 5% (11).
With perfect use, 1-2% (1-2 out of 100) of people who use the lactational amenorrhea method (LAM) will become pregnant (5, 12).
LAM relies on breastfeeding/chest feeding to prevent ovulation (6). The frequent sucking during exclusive breastfeeding decreases the usual production of gonadotropin-releasing hormone (GnRH) (13). This prevents the surge of luteinizing hormone (LH) (13). Without the LH surge, ovulation doesn’t occur (13). Three things must be present for LAM to be effective (2, 5):
You have had no period bleeding since birthing
You are six months or fewer postpartum
You primarily breastfeed/chest feed every 4 hours throughout the day and every 6 hours at night and use no more than 15% formula or pumped milk
9. Withdrawal (the “pull out” method) as a birth control method
Unintended pregnancy in one year of use: 20% (20 out of 100) typical use, 4% (4 out of 100) perfect use (14).
The withdrawal method involves removing the penis from the vagina before ejaculation (5). It does not protect against STIs. Couples who use withdrawal correctly each time may find that it works well for them (15). Perfect use can be difficult and the chance of pregnancy increases with typical use (15). Some research shows that pre-ejaculatory fluid (pre-cum) can leak before ejaculation (16). If this happens, sperm could enter the vagina even with perfect use (16).
10. Copper IUD
Unintended pregnancy in one year of use: Less than 1% (<1 out of 100) perfect use (5).
The copper IUD is hormone-free,works for ten years, and can be used as emergency contraception (5). Not only is it easy to take out, but you can also become pregnant right after removal (17). The copper IUD is a T-shaped piece of plastic wrapped in a thin copper wire that sends out copper ions that make it difficult for sperm to move and reach an egg (18). The IUD does not cause abortions because it does not disrupt an already implanted fertilized egg (5).
There are a few risks or side effects related to the copper IUD. An IUD could migrate out of the cervix or possibly go through the uterine wall (perforation) (17). Perforation is uncommon; throughout different studies, it has occurred in as little as 0.4 out of 1,000 people to 2.2 out of 1,000 people (5, 18, 19). If the IUD is inserted when an STI is present, there is a chance of pelvic inflammatory disease (PID) (29). Heavier bleeding and increased period pain can happen while using the copper IUD (18). This may decrease with time (18). 4-15% of people with a copper IUD have the device taken out before the end of the first year due to bleeding and period pain (21).
11. Sterilization (“getting your tubes tied”)
Unintended pregnancy in one year of use: less than 1% (<1 out of 100) perfect use (6).
The most popular method of contraception in the USA and around the world is tubal ligation, which is a sterilization procedure for people with uteruses (1). This is a surgical procedure that involves cutting/tying the fallopian tubes (5). Vasectomy is the sterilization procedure for people with scrotums (5). It involves clipping, cutting, or sealing off the vas deferens tube, which is involved in sperm transportation (5).
Sterilization is a permanent birth control option. Reversals (undoing a procedure) are possible, however they do not always work (5). There is up to a 7% chance of ectopic pregnancy after tubal ligation reversal (5). Instead of a reversal, in vitro fertilization is an alternative option for trying to conceive after having a tubal ligation . Vasectomies require follow up appointments to ensure that sperm is no longer present in ejaculate and backup contraception will be needed for those first few months (5).
12. Fertility awareness-based methods (FABMs)
Unintended pregnancy in one year of use FABMs:
Typical use: ranges from 12-23% (12 to 23 out of 100) depending on the method (16).
Perfect use: ranges from less than 1-5% (<1 to 5 out of 100) depending on the method (16).
Fertility awareness-based methods follow the changes in the menstrual cycle to predict ovulation and the days that sex could result in pregnancy (5, 16). If the person does not want to become pregnant, they avoid sex or use protection during that time (5, 16). To understand how FABMs work, it’s important to understand the basics of the menstrual cycle.
It’s okay if monitoring the ebb and flow of your body throughout your cycle feels intimidating. Not all people receive the same amount of education about the reproductive system and pregnancy prevention while growing up (22, 23). Learning how to use FABMs to prevent pregnancy allows you to gain a better understanding of that body system. If that sounds interesting to you, FABMs could be a good option.
FABMs allow you to avoid hormones, and are often free or cheaper compared to other methods, however FABMs do not protect against STIs.
Types of FABMs
There are several FABMs, each with their own “rules”. Some are more effective than others and none of them are effective if you do not use them as directed. They include the following methods:
Rhythm (Calendar) method
Standard Days method
Billings Ovulation method
Fertility tracking mobile apps
There are many menstrual tracking apps available, but only a few have been shown to include tools and information to help people prevent pregnancy (24). Only some are designed to be used as birth control, even fewer are cleared or approved by the Food and Drug Administration (FDA). Most apps do not accurately predict the days you could become pregnant because they don’t take into account how unique each person’s cycles are. Clue Birth Control was studied in a clinical trial, determined to be effective at preventing pregnancy, and cleared by the FDA (25).
Not all FABMs are equally effective
Methods like the Rhythm method or Standard Days method assume that the menstrual period always follows a certain number of days and ovulation happens on the same day of each cycle (27). A person trying to avoid pregnancy is instructed to avoid sex or use another birth control method on the days around their ovulation (26). These methods work best for people with cycles that are predictable and last 26-32 days (27).
Not all people with periods have 28-day cycles and ovulation may not happen on day 14 each month (5). Cycles vary for a number of reasons (5). If a method does not account for the uniqueness of a person’s cycle, predicting ovulation can be less accurate, which makes the chance of pregnancy more likely. Making a method a routine and always using it correctly may take time. Getting experience through practice or training may help (27).
Should I use a fertility awareness-based method?
Life stages or events that cause your periods to be unpredictable can make FABMs less effective in preventing pregnancy (5, 27). You may want to consider other types of birth control, if any of the following applies to you (27, 25):
You recently started having periods
You are close to menopause
You have just ended hormonal birth control
You have recently birthed
Your periods are unpredictable
Have a high risk of getting an STI
You are not able to avoid sex or use a barrier method during days with high risk of becoming pregnant
Your partner is not willing to participate in the FABM
If becoming pregnant would be dangerous to your health or be very damaging to your life, a more reliable form of birth control may be a better option.
Choosing a non-hormonal birth control option
There is no one perfect birth control method. The key is to learn about the different options and find the best match for you. This may change as your lifestyle changes and as you grow older.