Top things to know:
There are a range of non-hormonal options that vary in cost, effectiveness, and duration
Condoms are the only form of birth control that protect against both pregnancy and STIs (sexually transmitted infections)
There is no one perfect birth control method: the key is to learn about the different options and find the best match for you.
In 1960, the first hormonal contraceptive, Enovid, was approved by the FDA and came to be known simply as “the pill.” It was a breakthrough for women’s reproductive rights, and considered the first “lifestyle drug.” By the time of its 40th anniversary, the pill was used by over 200 million women worldwide (1).
Currently, over 60% of reproductive-aged women worldwide use some form of contraception (2). In the US, the pill is the most commonly used hormonal method of contraception (3).
Why use non-hormonal birth control?
Despite its popularity, hormonal birth control has some undesirable side effects and risks. It's associated with a higher incidence of breast cancer, blood clots, and stroke. Hormonal birth control with estrogen is also off-limits during breastfeeding (12).
People also report changes to mood, possible decreased libido, and increased risk of sexual pain problems when using the pill, though studies don't agree as to whether the pill increases these issues (4-7). These side effects have prompted some people to look for hormone-free alternatives.
Different types of non-hormonal birth control
We’ll go in-depth about all of your options, which include:
Fertility Awareness Methods / natural family planning
Copper IUDs (intrauterine devices)
Breastfeeding (lactational amenorrhea)
Effectiveness of non-hormonal birth control methods
Outercourse refers to a broad range of sexual activities, including kissing, hugging, handjobs, dry humping, masturbating with a partner, watching porn with a partner, massage, and breast play.
Some sex educators define outercourse as strictly no genital penetration or exchange of body fluids (8-9). Other sex educators are more liberal in their definition and limit the term to mean no penis-vagina sex, but allow for oral or anal sex (10).
One of the biggest problems with heterosexual sex is the fact that “sex” is narrowly defined as vaginal intercourse, which may not lead to orgasm for many women. In a US study of 1,055 women, only 18.4% were able to orgasm from vaginal intercourse alone, 36.6% needed clitoral stimulation to orgasm during intercourse, and another 36% felt it increased their pleasure (11).
Outercourse is not only for teenagers — it has the potential to be hugely pleasurable to people of all ages and levels of experience.
How effective is outercourse at preventing pregnancy?
Not only does outercourse eliminate the risk of pregnancy and reduce the risk of STIs (if contact with bodily fluids is avoided)—it can also be more likely to lead to female orgasm than intercourse.
External “male” condoms
Condoms are among the oldest forms of birth control. Ancient Egyptians created sheaths to be worn over the penis. In the 16th century, linen sheaths were used to prevent syphilis. Condoms made of animal intestines became popular in the 18th century. Today, condoms come in a wide variety of styles, shapes, and colors (12).
How effective are external condoms at preventing pregnancy?
Types of condoms
Latex: Most condoms are made of latex. You shouldn’t use oil-based lubricants with latex condoms though—only water or silicone-based lubes are appropriate.
Lambskin: This natural material doesn’t protect against STIs due to the presence of tiny pores that might allow the transmission of viral infections. Lambskin condoms can be used with water, oil, or silicone-based lubes.
Polyurethane and synthetic: More durable than latex and, unlike latex, can be used with oil-based lubes.
Internal “female” condom
The internal or “female” condom is made of polyurethane or nitrile and placed inside the vagina or anus during intercourse. It comes equipped with a ring on either end of the condom to hold it in place and prevent it from getting sucked into the vagina.
Planned Parenthood has an excellent primer about how to use it.
How effective are internal condoms at preventing pregnancy?
The internal (female) condom is typically less effective than the external (male) condom.
With perfect use, 5 out of every 100 women will become pregnant in a year. With typical use, 21 out of 100 will get pregnant (13).
Diaphragm and cervical cap
Diaphragms and cervical caps are both placed over the cervix and used with spermicide. Neither device is available without a prescription. Before Caya, a single size diaphragm, diaphragms had to be fitted by a doctor (12).
How effective are diaphragms and cervical caps at preventing pregnancy?
With perfect use of the diaphragm (which includes the use of a spermicide),16 out of 100 women will become pregnant in a given year. With typical use, 17 out of 100 will experience an unwanted pregnancy (13).
The contraceptive sponge is filled with spermicide and placed in the vagina before intercourse. It must be left in place for 6 hours after sexual activity. The sponge is available over the counter, but is less effective than the diaphragm (12).
How effective is the contraceptive sponge at preventing pregnancy?
The effectiveness also depends on if you’ve had a pregnancy lasting at least 22 weeks. For women who haven’t been pregnant, 9 out of 100 will become pregnant in a year with perfect use, with typical use 14 out of 100 women will become pregnant (13).
For people who have been pregnant for at least 22 weeks, the failure rate is 20 out of 100 women with perfect use. With typical use, 27 women out of 100 will experience an unwanted pregnancy (13).
Creams, foams, and suppositories
These are often used in conjunction with condoms, the cervical cap, and/or the diaphragm.
How effective are contraceptive foams and suppositories at preventing pregnancy?
In a given year, around 16 out of 100 women will become pregnant with perfect use. With typical use, 21 out of 100 women will get pregnant in a year (13).
Fertility Awareness Methods
Fertility awareness based methods (FAMs) have suffered from a PR problem. Unfortunately, they are linked in people’s minds with the unreliable “cross-your-fingers-and-count” rhythm method.
What’s the difference between FAMs and the rhythm method?
Rhythm method: Uses the counting of calendar days to predict ovulation, with the goal of avoiding sex on fertile days.
One of the problems with the rhythm method is that it is based on a faulty theory that the menstrual period always follows a 28-day cycle, with ovulation occurring on day 14.
This has led to a lot of surprised parents and bouncing babies.
Many people with periods don’t have 28-day cycles. Cycles vary for a number of reasons (stress can be one factor). Also, ovulation doesn’t always occur at 14 days—this is especially true if a cycle is longer or shorter than 28 days (12,14).
It should be noted: if a menstruating person has a regular period between 16 and 32 days (which is 78% of menstrual cycles), calendar-based methods can be effective as birth control (12).
Types of FAMs
There are several FAMs, each with their own rules. They include:
Standard Days Method
Billings Ovulation Method
There are also fertility apps that can help track your fertile window. Be sure to do your research: according to research in this area, many fertility apps aren't evidence-based, don't utilize FAMs, and aren't designed to be used as birth control (16).
How do FAMs work?
There are several official methods of fertility awareness. Each has slightly different rules. It’s important to follow an official method.
But to understand how all FAMs work, you’ll need to take a short detour to the basics of the menstrual cycle.
We have a guide to it here—take the time to make sure you understand what happens.
Before reading on: Make sure you know the phases of the cycle, what happens during ovulation, and the hormonal shifts that happen in each phase.
Indicators of fertility
Most FAMs require you to observe and record one or more indicators of fertility and avoid unprotected sex during the fertile window (14).
These indicators can include:
Luteinizing hormone (LH) tests (ovulation tests)
Position of your cervix
Basal body temperature
Insert your index and middle fingers in your vagina and feel deep inside for your cervix (14). Near ovulation, the cervix is softer (like your lips) and higher in the body, and the opening to the uterus (the internal os) is larger. After ovulation, the cervix closes, feels harder (like the tip of your nose), and drops lower in the body.
Building up to ovulation, your cervical fluid becomes increasingly wet and lubricative. Around ovulation, this fluid takes on an egg-white consistency. These changes can be observed by wiping your vulva (vaginal area) with toilet paper (14).
Cervical fluid is usually less observable and drier during non-fertile days. Sperm can live in wet, fertile-quality cervical mucus for up to 5 days, but they die in a matter of hours in the dry non-fertile cervical fluid that is present when progesterone levels are high (14).
Basal body temperature
After ovulation, many notice an increase in basal body temperature, which can be best detected in the morning using a thermometer.
How effective are FAMs at preventing pregnancy?
The effectiveness of FAMs depends on the method.
Perfect use of FAMs ranges from less than 1 pregnancy per 100 women to 5 in 100. Typical use ranges from 2 pregnancies in 100 to 23 pregnancies in 100 (17). Success using a FAM depends on your diligence in keeping track of fertility indicators, and how willing you are to forgo intercourse or use a barrier method during the fertile window.
Should I use a fertility awareness method?
If any of the following applies to you, you are not a good candidate for FAMs:
You have recently started having periods
You are close to menopause
You have just gone off hormonal birth control
You have recently been pregnant
You aren’t willing to track fertility indicators daily
You may want to consider other forms of birth control, as these life events can make it harder to read fertility signs (12).
Breastfeeding (Lactational amenorrhea)
The lactational amenorrhea method (LAM) is a non-hormonal birth control option for people who are exclusively breastfeeding an infant. This method relies on breastfeeding to prevent ovulation.
In order for LAM to be effective, you must feed your baby frequently and exclusively (no supplementing with formula or pumped milk) every 4 hours throughout the day and every 6 hours at night (12). The suction an infant applies to the breast is believed to prevent the usual production of gonadotropin-releasing hormone (GnRH), preventing the surge of luteinizing hormone (LH). Without the LH surge, ovulation doesn’t occur (27). The suction applied by a breast pump might not be reliable at preventing the LH surge. LAM can be used for 6 months after birth, or until your period returns, indicating you are ovulating (12).
How effective is the lactational amenorrhea method at preventing pregnancy?
With perfect use, fewer than 2 out of 100 people who use lactational amenorrhea will experience an unwanted pregnancy (25). There isn’t a good consensus on pregnancy rates for typical use of LAM, but one study of women who returned to work postpartum and were not able to breastfeed their infants on demand found the rate of unintended pregnancy using LAM escalated to around 5% (26).
Withdrawal (the “pull out” method)
This method is controversial, under-researched, and very common in certain parts of the world (18).
Withdrawal is often regarded as an extremely ineffective form of birth control. The research presents a more complex picture.
Perfect use: 4 out of every 100 women will become pregnant in a given year (13). “Perfect use” is defined here as male withdrawal before ejaculation in every sexual encounter (18).
Typical use: 20 out of 100 women will get pregnant in a year (13).
One of the primary concerns is whether pre-ejaculatory fluid (pre-cum) contains sperm. Some argue that any sperm present is due to a previous ejaculation, and that urinating prior to sex might enhance the effectiveness.
But, it might depend on each individual man's biology. In a study that examined the presence of sperm in 27 volunteers, it was found that 11 had sperm present in their pre-ejaculatory fluid. In 10 of these men, the sperm was motile (19).
Because there were several samples of precum collected from each volunteer, the researchers concluded: “It would appear from our study that some men repeatedly leak sperm in their pre-ejaculatory fluid while others do not.” (19).
All of the participants had urinated before sampling, so the results were not due to residual sperm from a prior ejaculation (19).
The copper IUD is hormone-free and approved for 10 years of use. The device has a thin copper wire wrapped around its plastic component, which releases copper ions. These ions generate an inflammatory response in the body, which then creates an inhospitable environment for sperm (20-21).
The copper IUD has these advantages:
Highly effective (less than 1 woman out of 100 will become pregnant in a year with both perfect and typical use)
Can double as emergency contraception (20).
And these potential disadvantages and side effects:
Displacement and migration of the device—as many as 10% of users will expel their IUD (21)
Perforation of the uterus
Increased menstrual bleeding
Increased risk of pelvic inflammatory disease in the 21 days following implantation (20).
Many of these side effects decrease with time. But because of pain and bleeding, 15% of copper IUD users have the device taken out before the end of the first year (22).
The most popular method of contraception in the US is sterilization (3). This is a surgical procedure that eliminates the possibility of conception, in most cases.
Next to abstinence, it is the most effective way of preventing pregnancy (10). Sterilization is often chosen by men and women who have decided that they don’t want more (or in some cases any) children.
Female sterilization (tubal ligation)
Tubal ligation is inexpensive and involves local or general anesthetic (10). In order to prevent the egg from traveling down the fallopian tubes and being fertilized by sperm, the fallopian tubes are either cut, tied, or cauterized (23).
During a minilaparotomy procedure, the fallopian tubes are brought through a small incision in the abdomen and either cut, removed, or clipped (23).
A laparoscopy procedure uses a laparoscope to view the internal organs and to close off the fallopian tubes through cutting, clipping, or sealing with an electric current. Usually, it entails two small incisions. The recovery is usually quick, and there are fewer side effects that the minilaparotomy (24).
Sterilization is an extremely effective form of birth control, with fewer than 1 woman in 100 becoming pregnant in a year with both perfect and typical use (13). The risks include the rare possibility of an ectopic pregnancy if conception does occur (23). Female sterilization is immediately effective.
Male sterilization (vasectomy)
This form of sterilization involves clipping, cutting, or sealing off the vas deferens tube, which is involved in sperm transportation.
Within 2-4 months, sperm will not be present in a man’s ejaculate. Contraception will be needed for those months. Vasectomies are safer than female sterilization, with risks limited to bleeding and infection.
Vasectomies can be performed with or without surgical incisions, and like female sterilization, less than 1 woman in 100 will become pregnant in a year (13).
So there you have it folks—these are some of your options. There is no one perfect birth control method that fits everybody. 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.
If you are interested in hormonal birth control, you can find that info on helloclue.com too.
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