Contraception

BARRIER METHODS
Barrier methods rely on setting up a barrier or physical separation between the sperm ejaculated from the man and the egg released by the ovulating woman. These methods set up the barrier within the vagina and serve to stop sperm from entering the opening of the cervix (the os), beyond which the egg may wait. Barrier methods prevent contact between any sperm and the egg (it only takes one out of the millions of sperm in each ejaculate to fertilize an egg and lead to a pregnancy).

It is crucial to note that the effectiveness of these barrier methods is significantly improved by the use of spermicides. In fact, one should always use a spermacide in addition to these methods below (some condoms already come with spermicide added). The most common barrier methods are as follows:

1. Male Condoms
2. Female Condoms
3. Diaphragm
4. Cervical Cap

If used correctly it is 92% to 96% effective    Back to top

HORMONAL METHODS
These methods rely on giving hormones to "trick" the female body into thinking it is already pregnant so that the ovaries will not release eggs.
 

1. The Pill

2. Depo-Provera

3. Norplant

To understand how these methods work, here is a brief look at a woman's menstrual cycle. During each cycle, the lining of the uterus builds up and matures under the influence of estrogen and progesterone. If no fertilized egg is implanted, the lining sheds during the "period", when levels of these hormones drop. After the period, hormone levels begin to rise, and the lining begins to build up again.

Each menstrual cycle lasts from the first day of the "period" to the first day of the next "period".  The length of each cycle is usually 28 days, but can vary widely among women and even from period to period from 17 days to 55 days.  A period, or menstrual flow, usually lasts 3 - 7 days.   About 14 days before the onset of the next period, and not necessarily halfway through the cycle, an egg is released from an ovary. This event, ovulation, is triggered by a rise in a particular hormone.  This means that if a woman's total cycle length is only 17 days (instead of the most common 28 days), she could potentially ovulate during her period and could conceive while menstruating.

If used correctly it is 92% to 96% effective    Back to top

Types of contraception - Barrier

CERVICAL CAP
History:
A cap to cover the cervix is an old idea which also lead to the diaphragm. In early civilization, beeswax and opium resin was used to shape a cap to cover the cervix thereby preventing unwanted pregnancies. It has been reported that Cassanova cut lemons and limes in half to use as a cervical cap. The citric acid was believed to be a spermicide. Since the early 1900s, the cervical cap has been made from latex rubber.

How it works:
The modern day cervical cap is a barrier contraceptive that blocks the passage of sperm through the cervical opening. The device is thimble-shaped and made of latex rubber and has a firm rim when compared to the diaphragm. It fits snugly over the cervix and is held in place by suction and support of the vaginal wall.Cervical caps are smaller and fit more tightly to the cervix than does a diaphragm.

Cervical caps can remain in place for up to 2 days without additional applications of spermicide, though some experts believe there is a small risk of Toxic Shock Syndrome. The cap remain in place for 8 hours after intercourse.

Who Should and Should Not Use It:
Cervical caps tend to be more effective in women who have not given birth in the past. One study showed that even with correct use, women who have given birth have a nearly a 25% chance of getting pregnant in a year with the cap. Other people who should avoid this method of contraception include those with active vaginal infections, an unusually short (or long) cervix, or history of abnormal pap smears.

Summary of the Cervical Cap

Effectiveness (Failure Rate)	Typical Use: 20 pregnancies/100 women/year (80% effective) Perfect Use: Use 9 pregnancies/100 women/year = 91% effective
Benefits	Essentially no side effects (unless allergic to all spermicides) Does not affect hormones DonÕt have to rely on the male partner Can be left in place for up to 48 hours, allowing spontaneous protected coitus Smaller than a diaphragm Less spermicide is used than with the diaphragm (allowing more pleasant oral sex)
Risks	Still no real protection against STDs (spermicides may prevent some STD transmission) If you donÕt remember to use it on or bring it with you, itÕs useless Somewhat more difficult to place and remove than diaphragm Can be disloged from cervix during intercourse Latex-allergic people should use non-latex caps, if available Theoretical risk of Toxic Shock Syndrome (2 - 3 per 100,000) for all women using vaginal barrier methods (diaphragm, cervical cap, sponge, female condom)
STD Protection	Poor to none though spermicide may kill some STDs
How to Get It	Your doctor must prescribe it. More information on this method is available from the manufacturer.
Cost	Initial Cost: $50 to $150, depending on ones health insurance coverage Ongoing cost: spermicide (averages to about 25 cents per coital act)

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DIAPHRAGM
History:
The diaphragm has been used for contraception since the early 1900s in Europe, and shortly thereafter in the United States. Design and comfort improvements have been made in the past century, but the basic concept remains the same.

How it works:
The diaphragm is a dome-shaped rubber cup with a flexible rim. The woman applies spermicide cream or gel on the inside of the cup and inserts it into her vagina with her fingers so that it fits snugly over her cervix. After intercourse, the diaphragm MUST be left in place for at least 6 hours. It should not be worn for more than 24 hours, however, because of the risk of Toxic Shock Syndrome.

A diaphragm provides effective contraception for 6 hours at a timeÑafter that, the diaphragm must be removed and cleaned. It can then be prepared with spermicide and reinserted before having intercourse again.

When not in use the diaphragm is stored in a plastic carrying case. Diaphragms are reusable and are not disposable. It is recommended that they be replaced every two years or so. Like other contraceptive methods, the diaphragm can be used during a womanÕs period.

A diaphragm must be prescribed by a doctor as it must be fitted to each individual womanÕs unique anatomical size and needs. There are four types of diaphragms, and they come in a variety of sizes. Precise fitting is importantÑtoo tight a fit may cause discomfort; too loose may allow sperm to enter the cervix and result in pregnancy.

Who Should and Should Not Use It:
A diaphragm requires the presence of mind and commitment to remember to use it before sex. Women who have frequent "unplanned" sex, who have sex three or more times per week, who are younger than 30 and who have had contraceptive failure in the past are more likely to get pregnant with this method. You must also be comfortable with inserting your fingers and the device deep into your vagina in order to properly use this device.

Summary of the Diaphragm

Effectiveness (Failure Rate)	Typical Use: 20 pregnancies/100 women/year (80% effective) Perfect Use: 6 pregnancies/100 women/year (94% effective)
Benefits	No side effects (unless allergic to all spermicides) Does not affect hormones DonÕt have to rely on male partner Possible lower risk of cervical cancer (controversial
Risks	Still no real protection against STDs (spermicides may prevent some STD transmission) If you donÕt remember to use it on or bring it with you, itÕs useless Latex-allergic people should use non-latex diaphragms Small risk of Toxic Shock Syndrome (2 - 3 per 100,000) for all women using vaginal barrier methods (diaphragm, cervical cap, sponge, female condom)
STD Protection	Poor to none though spermicide may kill some STDs
How to Get It	Your doctor must do a fitting and then prescribes it.
Cost	Initial Cost: $50 to $150, depending on ones health insurance coverage Ongoing cost: spermicide (averages to about 25 cents per coital act)

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FEMALE CONDOMS
History:
The female condom is a recent invention. The Reality condom is currently on the only one on the market.

How it works:
The female condom is a soft, loose fitting tube made of polyurethane. It is 7.8 cm in diameter by 17 cm long, and has a soft flexible polyurethane ring on either end. The closed end is inserted into the vagina and anchors the condom; the other ring remains outside the vagina. The external part of the condom protects some of the womanÕs vulva and part of the base of the penis during sex. The inside of the condom is coated with nonspermicidal lubricant, and the condom comes with extra lubricant to use on the outside. Each condom can only be used once, and is then thrown away. It can be inserted up to 8 hours before intercourse.

The female condom should NOT be used together with a male condom as both devices may then slip off. The polyurethane material of the condom is thinner than the latex of male condoms, but is less likely to tear or break. Unlike latex condoms, the female condom can be used with oil-based lubricants. Couples in the FDA study of female condoms liked the device and half would recommend it to friends. Only 7-8% of men and women did not like it.

Who Should and Should Not Use It:
If you are uncomfortable with inserting the condom into your body, or may have trouble remembering to have it around before sex, this may not be a good choice for you. You must be comfortable with inserting your fingers and the device deep into your vagina in order to properly use this device. Otherwise, this is an excellent choice especially for non-monogamous women or women who need protection against STDs, because this method protects against STDs even better than male condoms. Anyone at risk for an STD, with multiple sex partners, or who may be in a non-mutually faithful relationship should use a male or female condom for their own protection.

Summary of the Female Condom

Effectiveness (Failure Rate)	Typical Use: 21 pregnancies/100 women/year = 79% effective Perfect Use: 5 pregnancies/100 women/year = 95% effective
Benefits	STD protectionÑincludes external genitalia protection Low Cost Available without prescription
Risks	If you donÕt remember to use it on or bring it with you, itÕs useless Theoretical risk of Toxic Shock Syndrome (2 - 3 per 100,000) for all women using vaginal barrier methods (diaphragm, cervical cap, sponge, female condom)
STD Protection	Very good and second only to abstinence
How to Get It	Available over-the-counter at pharmacies and markets. The only brand currently available is Reality
Cost	$1 to 3 per female condom

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CONDOMS
As far back as 1350 BC,  there are records of Egyptian men wearing sheaths as decorative covers for their penises.  In the eighteenth century, condom use became popular for protection against infections and unwanted pregnancies.  The condom is usually made of latex rubber (another name for it is "a rubber") and is meant  to fit an erect penis.  Many condoms come lubricated and/or premedicated with spermicide (a chemical that kills sperm cells on contact).  Other condoms made of lamb intestines are more expensive and may not protect as well against sexually transmitted diseases.  Condoms are designed to keep semen from getting into the woman's vagina.  To maximize the protective benefits of condoms, they must be used correctly.

Condoms usually come rolled up in a package.  It will unroll to about 7 1/2  inches, though one should not unroll it until putting it on the erection.  A 1 3/8 inch ring is found on the open end to help prevent the condom from slipping off during use.  The closed end often has a nipple reservoir that catches semen and helps prevent the condom from breaking.  A high-quality latex condom has a failure rate of  1% - 2%, meaning that one can expect their condom to break, burst, contain a minute hole, or slip off, once or twice every 100 times of use.  Because of this, only abstinence is completely effective at preventing STDs.

To use a condom correctly, pinch the end (the nipple) to get the air out prior to placing it on the head of the penis.  This pinched-off space will be where the ejaculate collects and minimizes the risk of bursting the condom.  Roll the condom down the shaft of the erection, covering as much skin as possible (many STDs can spread from skin to skin contact even if there are no open sores or rashes present).  The condom must be unrolled onto the erection before any intercourse occurs as it is common to leak a small amount of semen from the stimulated penis prior to ejaculation.  If you are not using a lubricated condom, you should put K-Y Jelly or a spermicide onto the condom once it has been placed on the erection to lubricate and hence minimize the risk of tearing the condom during sexual relations.  NEVER use Vaseline (petroleum jelly) on the condom as it can dissolve the latex.  When withdrawing the condom-covered penis from the vagina or mouth, be sure to hold the rim to prevent it from slipping off and spilling sperm onto mucous membranes.  In case of an accidental spill around or in the vagina, insert spermicide cream, jelly, or foam gently in and around the vagina.  Do not douche.

Condoms can be bought at any drugstore, and usually come packaged in sets of 3 to 12.  To order condoms-by-mail, discretely and inexpensively, check out Condom Sense, or click on the condom picture.

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Types of contraception - Hormonal

NORPLANT
History / How it works:
Norplant is a recent invention which provides five years of continuous, highly effective contraception. It is a set of six tiny tubes inserted under the skin of the arm. Each tube contains a progestin called levonorgestrel which is slowly released and suppresses ovulation. It can be reversed at any time by removing the implants.

Who Should and Should Not Use It:
You may not be able to use this method if you have a previous history of breast cancer, stroke, heart disease, are taking seizure medication, or have advanced diabetes, or if you have bleeding from your vagina apart from your period. If you do not want to get pregnant for the next five years, this is a great choice. Often used by teenagers and women with many children for this reason. Excellent choice for women who have trouble remembering to use or using contraceptive methods at the time of sexual intercourseÑthe same advantage as Depo-Provera, but more long-term. In the fifth year of use, the Norplant set is replaced. Women who are on anti-seizure medicines should use a back-up contraceptive method with Norplant at all times because anti-seizure medications can cause Norplant to fail as a contraceptive. Also, women who are taking INH therapy for tuberculosis/exposure will have the same problem.

Summary of Norplant

Effectiveness (Failure Rate)	Typical Use = Perfect Use = 5 pregnancies per 1000 women per year = 99.5% effective
Benefits	See benefits for Depo-Provera Generally well-tolerated in terms of side effects Can be removed at any time regardless of your ability to pay for removal Cheaper in the long run over 5 years of use
Risks	Insertion and removal both require a minor surgical procedure Norplant removal can be technically challenging Higher risk of pregnancy at the end of the fifth year High initial cost unless you have Medicaid Insurance Small risk of irritation at implant site
STD Protection	Absolutely none
How to Get It	A prescription is needed. Visit your doctor or health care provider to see if this is right for you.
Cost	Total cost of insertion/visits: $500-700 Medicaid recipients: fully covered Norplant Foundation (1-800-760-9030) will provide free implants and removal certificates to women who do not have Medicaid but cannot afford to pay for Norplant.

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THE PILL (OCP)
History:
Also known as the oral contraceptive pill (OCP), the birth control pill was developed in the late 60's and played a key role in the Sexual Revolution.  The Pill contain synthetic either estrogen and progesterone or progesterone alone (the progesterone only or minipill). Estrogen and progesterone are hormones naturally produced by the ovaries.  One pill is taken every day.

How It Works:
As you recall, a woman's hormone levels rise and fall in the course of her menstrual cycle. These changing levels allow the release of an egg. Taking the Pill at a certain time every day without fail keeps these hormone levels at a steady level, and no egg is released. The "certain time every day" part is important as this is what keeps the levels very steady.

A pack of OCPs will usually contain 28 pills - one per day.  The first 21 pills contain hormones. The remaining 7 pills are placebo pills which contain no active ingredients and/or iron.  During these last 7 days of a pill cycle, the woman will menstruate (usually 2-5 days) due to the drop in hormone level in the blood.  After the 7 days are over, the woman starts with a new pack.

A woman can start taking the Pill on a certain day (usually Sunday) immediately after her menstrual period, or on any Sunday.  If she starts just after her period, she will theoretically be protected against pregnancy from day one, but should still use a back-up method (condoms and foam) for the first week (though some doctors suggest using a back-up method the entire month).  If she starts on any Sunday, she will not be fully protected against pregnancy for the first month and should definitely use a back-up method during the first month of pills.

There are many types of OCPs; your doctor or health care provider can help choose the right one for you.  The most common pills prescribed are the low dose (lower levels of hormones) pills such as Ortho-Novum 1/35 or 7/7/7, Triphasil, Lo/Ovral, Tri-Levlin,and many others.

Common Questions:

What if I miss a dose
Doctors generally recommend that if you miss one pill, you should take the missed pill as soon as you remember, and take the next pill at the usual time, AND USE A BACKUP METHOD (e.g., condoms + spermicide) FOR the remainder of your cycle. If you miss more than 1 pill, you should consult your doctor for advice on how to proceed. If you miss a pill AND miss a period, you may be pregnant.  Go see your doctor for a pregnancy test.

What if I want to get pregnant after stopping the Pill?
Almost all women can get pregnant within a year of stopping the pill. Most can get pregnant within a couple of months.

Does the Pill increase my chances of breast cancer?
This has not been conclusively proven and most experts fell the pill will not increase your risk of future breast cancer unless you have a previous history of breast cancer. (The pill has been shown to reduce your chance of ovarian and endometrial cancers.)

Who Should and Should Not use it:

1. DO NOT use the Pill if you are over 35 and smoke, even if you are trying to quit. Though the actual risk is low, smoking and the pill can be a deadly combination and women who do both are at a relatively high risk of developing blood clots in their veins which can travel to their heart and lungs and cause sudden death!  Even woman younger than 35 years old can die this way, so be sure your doctor knows you smoke if you are on the pill.

2. If you have a personal or family history of blood clots, stroke, heart or liver problems, strong family history of breast cancer, unexplained bleeding from your vagina, or migraine headaches, tell your doctor before you start on the pill.  Though most people with this medical history can take the pill, it is important for your doctor to know and inform you of the potential risks.

3. If you have a hard time remembering to take medications, don't choose this method, because you may forget to take this too!

4. IMPORTANT: If you are taking the pill and have difficulty breathing, chest pain, leg pain, headache or eye problems, see your doctor right away.
    

Summary of The Pill

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THE SHOT (DEPO-PROVERA, DEPOMEDROXYPROGESTERONE ACETATE INJECTION)
History:
Depo-provera (depomedroxyprogesterone or DMPA) is a progestin-only hormone injection given every 12 weeks (three months) and prevents ovulation. Approximately 1- 2% of US women select this option. The progestin hormone is released from the muscle into which it was injected, and suppresses levels of two other hormones involved in ovulation, namely FSH and LH. It is highly effective.

How it works:
Progestins prevent pregnancy in many ways. They inhibit ovulation, reduce sperm entry into the uterus by thickening and reducing cervical mucus, cause a thinner uterine lining, reduce the ability of the fallopian tubeÕs "fingers" to catch the egg.

Who Should and Should Not Use It:
This is a great method for women who want long-term birth control lasting for three (3) months at a time, without the hassle of taking pills each day. It is also convenient for women who have frequent sexual intercourse. It is safest for those with a monogamous relationship. Because it gives excellent protection against pregnancy, people with more than one partner or with a partner who may not be faithful may be lulled into not using condoms to protect against STDs. Therefore, it may give a false sense of security. While you may not get pregnant, you may getÑor giveÑHIV. You may not be able to use this method if you have a previous history of breast cancer, stroke, heart disease, are taking seizure medication, or have advanced diabetes, or if you have bleeding from your vagina apart from your period.

Summary of Depo-Provera

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Types of contraception - Intrauterine

IUD (INTRAUTERINE DEVICE)
History:
In the 1970s, the IUD was widely used in the US (10% of all women using contraception) until problems such as pelvic infections and deaths led to some devices being taken off of the market. Modern IUDs are good, safe, long-acting and cost-effective when used in the right patient populations.

How it works:
The IUD is a T-shaped device that comes with one of two active ingredients: copper or progesterone-containing. It is inserted into the uterus through the vagina by a physician and remains there for ten or fewer years. A string attached to the base of the T shape allows easy removal. Intrauterine devices are believed to work by preventing a sperm from fertilizing an egg. In the case of the copper IUD, copper ions in the uterine and tubal fluids are believed to prevent fertilization of the egg. Studies show that copper IUDs actually prevent fertilization of an egg and not implantation of a fertilized egg although theoretically this is possible (and is the common belief of how they work). The progesterone IUD works hormonally by preventing ovulation and thickening the cervical mucus to prevent sperm from entering the uterus. The copper IUD can be used for up to 10 years; the progesterone IUD can be used for 1 year.

Who Should and Should Not Use It:
This method is especially good for women in mutually faithful relationships, who have had at least one child, and are interested in reversible, long-term contraception. Women who are allergic to copper, who have sexual transmitted diseases (STDs), who have more than one sexual partner, who have had pelvic infections, who have fibroids or abnormal uteruses should not use IUDs as the risk of complications and infections goes up significantly.

Women who have not yet had children should avoid using IUDs as there is a higher incidence of certain complications. IUDs are not recommended for women who are taking steroids, have HIV or AIDS, have unexplained or abnormal vaginal bleeding, have cancer of the cervix or uterus or abnormal pap smears. Women with a history of breast cancer or a suspicious breast lump should not use the progesterone IUD, and should alert their doctor to the lump.

Summary of Depo-Provera

Gynefix

Gynefix is a new type of Intrauterine Device and works in the same way as the IUD. However, while traditional IUD's have a rigid frame, Gynefix has a flexible form - a row of copper beads which bend to fit the inside of the uterus. It is attached by a fine nylon thread to the wall of the uterus - making it less likely than a traditional IUD to be expelled by the womb.It also causes less painful side effects  and can be used either as a long term contraceptive, staying in place for five years, or as an emergency method of contraception within five days of unprotected intercourse or five days after expected ovulation.Gynefix offers no protection against sexually transmitted infections and HIV.

Gynefix has been shown to be more than 99% effective.

IUS (Intrauterine system)

A small plastic Intrauterine Device which contains the hormone, progestogen.  It is placed in the womb and stops sperm meeting an egg.It is effective as soon as it is placed in the womb and lasts for at least 5 years. It is useful for women with heavy, painful periods as it makes periods lighter, shorter and less painful.It offers no protection against sexually transmitted infections and HIV.  Women are taught to check for the threads of the IUS and other IUD's.

Over 99% effective.

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RHYTHM METHOD
History / How it works:
Although the rhythm method can work for some couples, the human body and its cycles can be unpredictable. This method operates on the premise of predicting ovulation by charting the woman's temperature at a certain time daily over several menstrual cycles and/or analyzing cervical mucus quality and thickness. Intercourse is then avoided around the time of predicted ovulation.

You may need to see your doctor or buy a book on the subject to effectively use this method.

Summary of Rhythm Method

Effectiveness (Failure Rate)	Effectiveness unknown, but at best is only 75%
Benefits	Better than nothing at all Inexpensive and requires no supplies
Risks	Unreliable - depends on ovulation. Depends on cooperation of male partner during abstinence periods Be prepared to get pregnant and possibly catch a sexually transmitted disease
STD Protection	Absolutely none.
How to Get It
Cost	Free

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STERILIZATION
History / How it works:
These methods are essentially permanent and should be considered irreversible. If you might, at any time in the future, desire to have children this is not the method for you. (That said, sterilization reversal procedures are performed with fair to good success rates for those who have later changed their minds.)

These techniques require invasive procedures to complete. Both operations (tubal ligation for women, vasectomy for men) are surgeries and carry risks associated with surgery (infection, bleeding, other surgical and anestesia complications).

Summary of tubal ligation (female sterilization)

Types of contraception -  Emergency

EMERGENCY CONTRACEPTION (THE "MORNING AFTER" PILL)
History:
Originally developed in the 1960s as treatment for rape victims, this method has been improved upon over time and continues to have active research. Though it has no effect on preventing STDs / STIs, it is a second chance to avoid an unintended pregnancy. (The chance of getting pregnant after intercourse is calculated to be between 2% and 30%.) Emergency contraception methods can use by women to prevent pregnancy after intercourse in the case of unused contraception (e.g., sexual assault, forgot to use contraception) or contraception failure (e.g., condom breakage, IUD expulsion, etc). Emergency contraception methods are not as effective as the contraceptive methods listed previously; the true effectiveness is unknown but is estimated to be above 80% if used within 72 hours from intercourse. Because of side effects (nausea, vomiting, heavy periods, breast tenderness) and lower effectiveness, emergency contraception should not be used as the primary means of contraception.

How it works:
Emergency contraception pills are thought to work through a number of effects mostly by preventing fertilization through disrupting ovulation or interfering with the movement of sperm towards the egg. Depending on what sort of emergency contraception is used, other possible mechanisms include interfering with the corpus luteum or preventing implantation (i.e., they do not seem to cause abortions, rather they prevent fertilization in the first place).

How to Get it:
Most current birth control pills can be used for emergency contraception though only the Preven emergency contraception pill has been approved in the US for use. Call or visit your doctor, health care clinic, or emergency room to learn how to take the medicine or get it prescribed. Click here for a list of local clinics, or call 1-888-NOT-2-LATE for information about method options and provider referral.

Emergency Contraceptive Pills (most commonly used): This is a regimen of combined estrogen-progesterone oral contraceptive pills taken within 72 hours of unprotected intercourse. It may cause significant nausea and vomiting.

Progestin-only minipills can also be used; they work through a similar mechanism as OCPs and may be more effective than the estrogen + progesterone combinations

Copper IUD insertion is a less common method, but works within 5 days of intercourse and may be 98% effective. Copper ions act to prevent fertilization.

RU-486 can be used only within 49 days of the beginning of the woman's last menstrual period. The woman takes three mifepristone pills. Two days later, she returns to the doctor to swallow a second drug, misoprostol, that causes uterine contractions to expel the embryo. The woman then will return for a follow-up visit within two weeks to be sure the abortion is complete.

The FDA will allow mifepristone to be distributed only to doctors trained to accurately diagnose the duration of pregnancy and to detect ectopic, or tubal, pregnancies, because those women cannot receive mifepristone. Also, the FDA restricted mifepristone's use to doctors who can operate in case a surgical abortion is needed to finish the job or in cases of severe bleeding - or to doctors who have made advance arrangements for a surgeon to provide such care to their patients.

Studies show mifepristone is 92 percent to 95 percent effective in causing early abortion, by blocking action of a hormone essential for maintaining pregnancy. Without that hormone, progesterone, the uterine lining thins so an embryo cannot remain implanted and grow. The pill-induced abortion can be painful, causing bleeding and nausea. Heavy bleeding is a potentially serious side effect but one the FDA determined is rare. In safety testing of the first 2,100 American women who took mifepristone, four bled enough to need a transfusion.

Listed below are the most common formulations and emergency contraception medications available. Consult your own physician before using any of these medications for this purpose.

Common Emergency Contraception Medications

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Reality, The Female Condom

The female condom is a soft, loose-fitting plastic pouch made of polyurethane (not latex) that lines the vagina. It has a semi-stiff plastic ring at each end. The inner ring is used to insert the device inside the vagina and hold it in place. The outer ring partly covers the labia area and holds the condom open. The female condom is market in the United States by Wisconsin Pharmaceuticals under the name Reality. In the United Kingdom and Canada it is marketed under the name Femidom. Market acceptance testing has been going on for over a year, and on August 15, 1994, Wisconsin Pharmaceuticals began widespread marketing of Reality.

In theory, the polyurethane construction of the female condom makes it viable to use with oil-based lubricants, and Wisconsin Pharmaceutical's hotline states that this is safe. The female condom is also the best viable alternative available for those people who are allergic to latex. The female condom should not be used for anal sex-- the anus has no upper end and the outer ring is not enough to prevent it from being pushed into the anus and become lost.

Inserting the female condom.

The female condom can be inserted up to 8 hours before sex. However, most women prefer to insert it between 2 and 20 minutes prior to sexual intercourse. The condom should be removed immediately after sex.

Squeeze the inner ring with your thumb and middle finger, placing your index finger down upon the plastic inside the inner ring. Still squeezing, spread the labia apart. With your hand positioned with your palm towards you, insert the female condom into the vagina. Push the inner ring and pouch the rest of the way into the vagina until the inner ring is up past the pubic bone. The outside ring should now lie against the vulva, covering the opening of the vagina.

The female condom after insertion

During intercourse, the female condom may move or shift. It should not be pushed into the vagina, and the outer ring is intended to prevent this. However, it may happen. If so, stop intercourse, fix the ring, and apply more lubricant to the penis or in the pouch.

After intercourse, the female condom should be disposed of in a trashcan. Do not flush the female condom in the toilet.

Effectiveness

The pregnancy rate for the female condom under normal use is expected to be comparable to that of the male condom (13%). However, because of a lack of familiarity with the device, initial results have been discouraging, with rates as high as double that (26%). The female condom requires the use of an external, water-soluble lubricant. A package of Reality, the brand available in the United States, comes with three female condoms and a small bottle of lubricant (1/2 oz). The lubricant is comparable in quality to Astroglide.

The female condom requires practice to use properly. Be prepared to take your time inserting it the first time. Those who have experience using a diaphragm will find the process familiar.

The female condom has not been tested in its efficiency to prevent disease. It is expected to be as effective as a male condom. However, the insertion process calls for two steps: inserting the ring, where the hand is outside the pouch and in contact with vaginal fluids, and then fitting the ring, where the fingers are inside the pouch, thus spreading those fluids about the pouch where the penis will go. While there are solutions to this problem (have each partner do one of these steps, wear gloves for half the process, or wash hands before the fitting stage), none of them are adequate for most people. The female condom should not be considered a viable protection for STDs in cases where the woman is suspected to have a mucosal infection such as herpes or HPV.

In the United States, Reality has been available primarily through Planned Parenthood. Wisconsin Pharmaceuticals has started shipping to drug stores and it should be available throughout the U.S. in the last quarter of 1994. Reality is somewhat pricey-- three condoms and a small bottle of lubricant cost approximately $7.00 US.

Personal observations.

My wife and I were part of a marketing test group for Reality. It's expensive, difficult to learn how to use, and not very effective at preventing STDs without extraordinary measures. However, I happen to like it. Without enough lubricant, it will stick to the skin of the penis and act just as a male condom. With enough lubricant it feels much better than a male condom-- the penis responds mostly to friction, and that's what Reality supplies. A friend of mine who is allergic to latex thinks they're a gift from heaven. Some gay men have tried using Reality for anal sex, with mixed but generally positive results. Wisconsin Pharmaceutical has announced, rather loudly, that they have no intention of making the modification necessary to make Reality truly viable for anal sex.

Reality comes with an instruction booklet. The booklet is hilarious, mostly because of the name of the product. For example:

• Use a new Reality with each and every sex act.

• Read instructions carefully before using Reality.

• The booklet explains how to use Reality.

• Don't tear Reality.

• Reality only works when you use it.

• Make sure Reality is not twisted after insertion.

• Reality should not be noisy during sex.

• Reality may shift during sex.

• Keep Reality out of the reach of children.

If you have the opportunity to purchase and try Reality, do so at least once. Get three condoms and a bottle of lubricant and try them out. Any new reproductive technology is worthwhile, and who knows-- you might like them.

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Condom Sense

This is a posting of information about types of condoms which are significantly larger or smaller than average. I got it out of a book called "The Condom Book" or something similarly imaginative.