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Roe v. Wade and Birth Control: What to Know About Access and Options - The New York Times

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From condoms to IUDs to tubal ligation, experts weigh in on how to assess and obtain birth control options.

Over the past few decades, the number of birth control methods available in the United States has grown sharply. Women today are faced with a dizzying array of new pills, implants, gels and patches.

Despite these advances, experts say a birth control pill for men is unlikely to hit the shelves any time soon, and the maze of options for women can be particularly confusing because each contraceptive carries its own set of precautions and side effects. The recent leak of a draft Supreme Court opinion on Roe v. Wade has also raised questions about whether states might be able to tighten their regulation of contraceptives.

The New York Times spoke with seven gynecologists and reproductive health experts, seeking to identify and explain the types of contraceptives currently available, how to get them and what side effects and risks they carry.

The leaked draft of the Supreme Court opinion that would overturn Roe v. Wade does not indicate that the Court would revisit past decisions about birth control. “We emphasize that our decision concerns the constitutional right to abortion and no other right,” Justice Samuel Alito wrote. “Nothing in this opinion should be understood to cast doubt on precedents that do not concern abortion.”

However, some legal experts have raised concerns that justices could apply the argument for overturning Roe to limiting access to contraceptives. As a result, advocates worry that legislators could use a ban on abortion to make birth control less available. The state legislature if Louisiana advanced a bill this week that would classify abortion as homicide. Opponents of the proposal raised flags, saying that legislation could technically criminalize some forms of birth control as well.

“We’ve seen folks falsely equating emergency contraceptives and IUDs with abortion,” said Mara Gandal-Powers, director of birth control access and senior counsel at the National Women’s Law Center. “That’s certainly something I’m concerned about.”

Condoms are the most popular option for over-the-counter birth control, and don’t require a prescription or doctor’s visit. They can help prevent pregnancy and sexually transmitted infections, but not everyone knows how to use them correctly, said Dr. Melissa Simon, vice chair for research at the department of obstetrics and gynecology at the Northwestern University Feinberg School of Medicine. And condoms fail about 13 percent of the time, according to the Centers for Disease Control and Prevention.

Spermicide, a sperm-killing chemical that comes in gels, foams and the like, is also sold over-the-counter but is not considered effective as other options at preventing pregnancy by itself, said Dr. Monica Woll Rosen, an OB-GYN at University of Michigan Medical School.

Two other short-acting contraceptives, diaphragms and cervical caps, don’t require a prescription. Women should typically speak to a doctor about using them, and they’ve largely fallen out of favor, experts said, with many long-term options for birth control on the market.

One of the newest forms of birth control to hit the market, Phexxi, is a hormone-free option that requires a prescription. It was about 93 percent effective when used correctly in clinical trials reviewed by the Food and Drug Administration, and 86 percent effective in practice.

But it’s a gel that the user inserts in the vagina before intercourse, not a long-acting form of contraception, and some reported side effects include vaginal burning and itching. Also, because Phexxi is so new, some insurance companies may not cover it.

Hormonal birth control pills can be highly effective if taken at the same time every day. There are hundreds of birth control pills on the market, and the most common ones use a combination of estrogen and progestin, which are both hormones, to stop ovulation.

Some people report mood changes related to the pill and other forms of hormonal birth control. One review of studies found that users of hormonal contraceptives were more likely than nonusers to have higher rates of depression, anxiety, fatigue and anger.

Sometimes called the “mini pill,” this form of birth control contains only progestin, a synthetic form of the progesterone hormone. The biggest advantage of the progestin-only pill is that is doesn’t contain estrogen, making it more accessible to people who are at risk of developing medical complications from the hormone, said Dr. Aparna Sridhar, an associate clinical professor in obstetrics and gynecology at UCLA Health.

“For those who actually cannot tolerate estrogen for any reason, the progestin-only pill is a great option,” Dr. Sridhar said.

The progestin-only pill is about as effective as the combination pill if it’s used correctly, she said.

The patch uses a combination of hormones similar to those found in the ring and many oral contraceptives — estrogen and progestin — but instead of taking a daily pill, the user places a patch on their skin once a week.

Patches come in packs of three; the user puts on a new patch each week for three weeks, then has a patch-free week during which a period typically occurs. Patches can be worn when showering or swimming.

“It’s great for people who can’t remember or don’t want to take a pill every single day,” said Dr. Julia Cron, vice chair of the department of obstetrics and gynecology at Weill Cornell Medicine/New York-Presbyterian. “It also gives you some of the other advantages that the pill gives, like cycle control, less bleeding, less pain.”

Side effects include irregular bleeding, headaches, breast tenderness and, for some, nausea and mood changes, Dr. Cron said.

There are two vaginal rings available: the NuvaRing, which lasts for about a month, and the Annovera ring, which lasts for about a year. For both rings, the user inserts the ring, leaves it in for about three weeks and then removes for a week; someone using the NuvaRing would insert a new ring each month, while someone using the Annovera ring will reuse the same ring. They use similar hormones as the pill and the patch, but because they can be worn for longer periods of time, some find them less bothersome than the pill, which has to be taken every day, and the patch, which has to be applied nearly every week.

Because the ring contains estrogen, it can have similar side effects to the pill or patch, said Dr. Siripanth Nippita, a clinical assistant professor of obstetrics and gynecology at NYU Langone Health. These can include mood changes, nausea, breast tenderness and headaches.

Whitney Curtis for The New York Times

Women’s health experts consider intrauterine devices, or IUDs, to be among the most effective forms of birth control, in part because people using them don’t need to remember to take or apply them, like a pill or a patch. A doctor inserts one of the T-shaped devices into the uterus, a procedure that typically lasts five minutes. Depending on the type, the IUD can remain effective for three to 12 years.

There are two types of IUDs currently available:

Hormonal, which secretes progestin. “Very little” of the hormone is absorbed into the bloodstream, compared with oral contraceptive pills, Dr. Rosen said, so patients tend to experience fewer mood-related side effects. People who receive hormonal IUDs can have abnormal bleeding or spotting during the first three to six months after insertion. Then the bleeding typically becomes lighter and more regular, or goes away completely.

Copper, which doesn’t contain hormones. However, people with heavy or painful periods may want to avoid copper IUDs, Dr. Rosen said, because they can cause longer periods and heavier flows for some.

Nexplanon is a type of implant that is inserted under the skin of the upper arm and lasts for around three years. It also has the lowest failure rate of all birth control methods, according to Dr. Nippita.

A doctor or nurse inserts the small rod, which is about the length of a matchstick, and the process takes only a few minutes. No pelvic exam is required.

Side effects can vary from person to person. About a third of patients will experience “daily, abnormal, bothersome” spotting, said Dr. Rosen; another third will not experience bleeding at all; and the other third will simply have lighter, infrequent spotting. Some people with the implant also report mood swings, headaches, weight gain and acne.

Depo-Provera is an injection that contains progestin and protects against pregnancy for three months. A health care provider typically administers it, in an arm or the buttocks, every 12 to 14 weeks.

Some people may experience spotting or other period irregularities after the first few shots, but they usually go away over time. Weight gain can also be a side effect for some people. Depo-Provera can also cause depression, migraines, seizures and liver problems in some patients.

Tubal ligation, or getting your “tubes tied,” is a highly effective procedure that will permanently protect against pregnancy, but it’s not reversible, so women need to be certain about never wanting to become pregnant.

The minimally invasive procedure can be done during a C-section or right after a vaginal birth as well as at any other point. Another option is a salpingectomy, a procedure that involves removing one or both fallopian tubes.

Vasectomies are quick, highly effective surgeries in which doctors cut and seal sperm-carrying tubes in the scrotum.

The procedure typically takes 20 minutes and can be performed in an office setting or under conscious sedation, said Dr. Puneet Masson, the director of Male Reproductive Medicine and Surgery and an assistant professor of clinical urology in surgery at Penn Medicine.

While vasectomies can be reversed, patients should consider the procedure to be permanent contraception, Dr. Masson said.

“If you’re looking for a reversible form of contraception, I would move away from both vasectomy and female sterilization,” Dr. Cron of Weill Cornell Medicine/New York-Presbyterian said. “It’s really not meant for somebody that has any doubts about future fertility.”

Scott Olson/Getty Images

There are two “morning-after pills” available: Plan B, which is available over the counter at drugstores and pharmacies, and Ella, which requires a prescription. Both delay ovulation and allow sperm in the reproductive tract to die out.

People concerned about pregnancy should take Plan B within 72 hours after unprotected sex. Ella can be effective for up to five days after unprotected sex. For both medications, “the sooner you take it after unprotected sex, the better,” Dr. Nippita said. The pills are made of different ingredients: Plan B contains levonorgestrel, while the active ingredient in Ella is ulipristal acetate.

These pills may make you nauseous or cause vomiting, and your next period might be shorter than usual after taking them.

According to the C.D.C., the copper IUD can be used as emergency contraception, but it needs to be placed within five days of unprotected sex. Research shows the hormonal IUD may also be effective as emergency contraception.

Several popular types of birth control, including many of the oral contraceptives, the patch and the ring, contain estrogen, so you’ll see a lot of the same concerns about who can and can’t use them.

Anyone with high blood pressure, a history of blood clots or strokes, some forms of breast cancer or migraine headaches with aura, may be advised to find other methods. Also, anyone who is over 35 and smokes cigarettes may have a higher risk of complications like strokes.

One of the most difficult parts of navigating birth control options can be parsing the literature on weight limits for contraceptives. Although there is conflicting data on how effective hormonal contraceptives are for people above a certain body mass index, or B.M.I., some birth control methods may not be recommended for people who are overweight or those with obesity.

There is also contradictory guidance on whether people who have a certain B.M.I. can or should take emergency contraceptive pills. Clinical trials showed that Plan B and Ella are most effective for women who are under a B.M.I. of 30, Dr. Nippita said. However, the F.D.A. stated in 2016 that it had reviewed the available scientific data on whether emergency contraceptives containing levonorgestrel, like Plan B, were effective in women who weighed over 165 pounds, and concluded that “all women, regardless of how much they weigh, can use these products to prevent unintended pregnancy following unprotected sexual intercourse or contraceptive failure.” Dr. Nippita said that she would not preclude prescribing emergency contraception to a patient based on B.M.I.

Between Medicaid and the Affordable Care Act’s requirements for insurance companies, birth control costs should be covered, said Ms. Gandal-Powers, of the National Women’s Law Center. That means most people should have no out-of-pocket costs, including for doctor’s visits associated with obtaining birth control, such as consultations and implantations for IUDs. But insurance coverage doesn’t always translate into access, she said. “Just because you have coverage doesn’t mean you have a provider near you who can insert an IUD,” she said.

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