There are so many options available for contraception, and so much conflicting information about what’s safe, that it can be overwhelming to choose. Add to that, if you’re here on my website, there’s a good chance you’re someone who wants to keep things as close to natural – and as safe for your wonderful body – as possible. Perhaps you’ve also heard about some negative press about the Pill online.
So how do you choose the safest, most effective contraception? What are the risks you need to be aware of, as well as other pros and cons? As you’ll learn, this decision is very individual and also can change throughout our lives. Let’s explore this further.
How to Choose Birth Control Based on Your Current Needs
When it comes to choosing the best form of birth control for you, there’s not usually one right answer, nor a single answer for a lifetime. Your contraception needs have to take quite a few factors into consideration, including:
- your comfort level using hormonal contraceptives
- your personal risk factors
- what your contraception needs, goals, and preferences are at this time in your life
In this article, I share the options I most frequently recommend in my medical practice based on these factors and years of helping women determine what methods they feel are best for them. Then, because it’s such a widely used method and there’s a lot of confusing information about it on the internet, I also share need-to-know facts about the Pill so you can ultimately choose the best form of birth control for your needs and preferences.
The 3 Forms of Birth Control I Recommend the Most
Based on effectiveness, ease, cost, safety, and the fact that most women who seek my care would prefer to avoid the Pill unless it’s necessary for hormonal reasons (rather than solely for contraception), the methods I lean into most frequently are condoms, fertility awareness, and the IUD. Here’s why:
If you’re looking for a non-hormonal option that’s highly effective when used correctly and allows you to confidently have sex anytime of the month without having to add on an additional method, condoms might be a perfect choice for you.
They’re one of the best forms of birth control options for many for several reasons. Here are the pros:
- When used correctly, condoms have up to a 98 percent efficacy rate of preventing pregnancy. However, as Planned Parenthood notes, the actual rate of effectiveness may be closer to 85 percent when you factor in causes of condom failure, such as breakage, slippage, incorrect usage, and using them past their expiration date.
- Physical barrier protection not only functions as a contraceptive, but also reduces the risk of contracting sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). However, please note they aren’t as effective at preventing the transmission of genital ulcer diseases (such as herpes and syphilis) and human papillomavirus (HPV), since their main form of transmission is through contact with infected skin or mucosal areas. Because of these risks, it’s incredibly important to exchange the need-to-know sexual health history details with your partner(s) and get tested regularly for STIs.
- Condoms are generally affordable, simple to use, and don’t require visits to the doctor or a prescription to access. Just be sure to use the right condom size and apply them correctly to ensure that they’re as effective as possible.
The Downside of Condoms
While condoms are a low-risk, easy to use form of contraception, there are some things you need to know:
- Some people don’t like to wear condoms or enjoy the full sensations of intercourse with them, so you need to ensure that you and your partner are on the same page when choosing this type of birth control.
- You need to be prepared to have them on hand and use them each and every time you have intercourse to avoid pregnancy, especially if condoms are the only type of birth control you’re using.
- Some condoms aren’t entirely vaginal-health friendly: Whenever possible, use condoms and lubricants that are vaginal pH-friendly and as natural as possible. Fortunately, there are fair trade latex and non-toxic options to choose from that support a healthy vaginal environment. Such natural alternatives can help prevent dryness, irritation, the growth of bacteria, and yeast infections.
2. Fertility Awareness Methods
Also known as Natural Family Planning, fertility awareness methods involve tracking a range of fertility signals throughout your menstrual cycle and abstaining from unprotected intercourse during the narrow window of your fertile days each menstrual cycle.
There are several approaches you can take for natural family planning. Here’s a quick overview of each:
- Menstrual Cycle Tracking or the Standard Days Method: With these methods you pay attention to the day of your menstrual cycle you're on (Day 1 being the first day of your period, and the final day of your cycle being the day before your next period starts). Then you avoid intercourse or use a barrier contraceptive on the days in which you’re fertile. This method is most reliable if your period is consistent and your menstrual cycle ranges between 26 to 32 days long (the Standard Days Method specifically is only meant to be used by women with menstrual cycles in this range).
- Cervical Mucus Method: Your cervical fluid varies in color, consistency, and volume throughout your menstrual cycle, and observing these changes can reliably determine when you’re most fertile. Cervical mucus is typically clear, thin, slippery, and most plentiful a few days prior to ovulation until right after ovulation occurs. The presence of this type of cervical fluid (also known as Spinnbarkeit) clues you in to avoid intercourse or use a physical contraceptive during this time.
- Basal Body Temperature (BBT) Method: This method of family planning entails taking your temperature every day upon waking up. using a Basal Body Thermometer. Under the influence of progesterone after ovulation, your body temperature increases by a half degree to one degree Fahrenheit during ovulation and for about 10 days post ovulation, almost to the end of your menstrual cycle. You’re most fertile two to three days before your temperature rises, so tracking these trends over time can inform you to avoid intercourse on those days or use an alternate form of protection, such as condoms.
- Sympto-Thermal Method (STM): STM employs a combination of natural family planning methods outlined above. True to its name, STM involves tracking symptoms (such as cervical mucus) and recording your daily temperature via the BBT Method.
Fertility awareness methods also provide the added benefit of truly getting to know your body. As the saying goes, knowledge is power – and understanding your body’s rhythms and fluctuations can help guide many other aspects of your life. Tracking your cycle won’t only help prevent pregnancy, but can also inform you of trends related to your:
- energy levels
- sleep patterns
- physical activity and wellness
Understanding and tracking your cycle – interspersed with condom use for protection when you’re sexually active during your fertile window and for STI protection – can be a win-win. It provides you with an incredible window into how your body works while also allowing you to avoid hormonal or more invasive forms of contraception.
The Downside of Fertility Awareness as Contraception
While a safe and generally effective method, there are some downsides to be aware of:
- It can take several months to learn to accurately assess your cycles, so this natural form of birth control admittedly takes more time to onboard – as well as planning and commitment to use effectively – compared to other methods. However, the results can be well worth the time and effort involved.
- While natural family planning can be up to 99 percent effective when done properly, the real-life success of this method is closer to 76 to 88 percent once you factor in human error (such as forgetting to track your cycle and especially your fertility signals) and other instances that may impact accurate readings (such as elevated body temperature due to illness, or irregular cycles due to travel or stress).
- As one of my old friends said, this method is great except we most want to f#!K when we’re fertile – so you have to remember to use another method (i.e. condoms) during your fertility window. That means you need to understand the pros – and cons – of condom use, especially remembering to have them on hand when you need them most!
What about fertility tracking apps?
A fertility tracking app can be a wonderfully convenient way to practice fertility awareness and developers promise a high level of accuracy. Some of these apps are even FDA approved.
But fertility tracking apps also have their downsides:
- Most apps are designed on the premise that women have a 28-day menstrual cycle with regular mid-cycle ovulation. If yours doesn’t fit that bill, you might not be getting a reliable picture of when you’re ovulating, which defeats the purpose if you’re trying to avoid pregnancy! To drive this point home, a 2020 study found that most cycle tracking apps “are of low quality, and users should be wary of relying on their predictions to avoid pregnancy or to maximize chances of conception.” Further, a 2016 study done by researchers at Columbia University found that of 108 cycle tracking apps, only 20 contained accurate information. So even when using an app, always pay attention to your own “hormone intelligence” alongside it, using the methods and insights described above.
- Troublingly, there’s been some nefarious behavior in the world of period tracking apps. For example, the popular cycle tracking app Flo has given private information to Google and Facebook without users’ consent, such as when women were having their periods or intended to get pregnant. If you prefer the convenience of using an app, which I understand, make sure the app guarantees that your personal details aren’t being shared without your permission.
- An app doesn’t prevent pregnancy; it only provides insight, based on a generic algorithm, as to when you might be in your fertile window. With that in mind, you’ll still need to use condoms for contraception if you have intercourse during your fertile days.
3. The IUD
The intrauterine device (IUD) is a T-shaped medical device that a physician or midwife inserts into the uterus. IUDs work by thickening cervical mucus to prevent conception.
As we learned above, cervical mucus is thin and slippery when you’re fertile. Conversely, when it’s thick and opaque, it functions as a shield to block sperm from reaching an egg for successful fertilization. Additionally, IUDs thin out the uterine lining, making it inhospitable for a fertilized egg to implant into, and the copper in copper IUDs is toxic to sperm, making them less able to fertilize an ovum.
The IUD comes in two forms:
- Copper IUD: If you choose to go with an IUD for birth control, I highly recommend opting for the copper IUD. It’s safe and effective at preventing pregnancy and doesn’t require introducing extra hormones into your body. The copper IUD is also a convenient option if pregnancy isn’t on your radar for a while. Once inserted, the copper IUD can work for up to 12 years.
- Progestin IUD: This type of IUD releases small amounts of the hormone progestin in the body to avoid pregnancy. There are four brands of progestin IUDs available in the US that last for varying lengths of time:
- Mirena (7 years)
- Liletta (7 years)
- Kyleena (5 years)
- Skyla (3 years)
While only 6.1 percent of American women used IUDs in 2018, you may be surprised to learn that it’s the most popular type of birth control worldwide – particularly in Europe and Asia. They’re considered the most effective form of contraception available (save for abstinence and sterilization) with a 99 percent rate of success. While you may have heard horror stories about IUDs from decades past, there have been many developments and advancements since, so it’s safe to put that bad PR to rest.
Aside from the overall safety and efficacy of IUDs at preventing contraception and the “one and done” ease of use, another benefit is that if you decide to get pregnant, there’s no waiting period required. Once you get the IUD removed, you can start trying to get pregnant immediately; a delayed return to fertility is not a typical side effect of IUD use. Additionally, in a 2015 study, participants who normally had heavy periods experienced an 80 percent reduction in median menstrual blood loss within four months of inserting the Mirena IUD, with that number climbing to 95 percent within a year.
The Downsides of the IUD
An IUD may not be the right choice for everyone. Here are some of the downsides:
- The process of inserting the IUD can be uncomfortable or even painful. Intense cramping – particularly for those who haven’t given birth before – is fairly common.
- Spotting and irregular periods are common with the IUD, though it tends to subside within six or so months.
- The copper IUD commonly causes heavier flow and aches throughout the first year after insertion. If you’re one of the many women who struggle with heavy periods – so much so that it impacts your quality of life each and every month – this feature of the copper IUDs may sway you to choose another form of birth control on this list.
- Some women report experiencing a new onset of depression with the hormone-releasing IUD.
- If your weight tends to fluctuate or you experience significant weight loss/gain at some point, you’ll need to have the IUD refitted to ensure that it remains effective.
- The IUD isn’t suitable for those with active pelvic inflammatory disease (PID) or uterine abnormalities. In addition, the progestin IUD isn’t suitable for those who have a history of cirrhosis, blood clotting disorders, and/or breast cancer.
- Plus, though these are rare, there are some risks including:
- perforation of the uterus when it’s being inserted
- expulsion of the IUD
- development of PID
- increased risk of ectopic pregnancy should pregnancy occur with an IUD in place
IUDs, Copper Toxicity, and Autoimmune Disease
Some women are concerned about the potential risk of developing copper toxicity and autoimmune conditions with IUDs, based on anecdotal stories on the internet. While I think the jury is still out on whether there is an association, the bottom line is that at this time, there’s no conclusive evidence demonstrating a strong correlation in either case. However, one 2014 study did find that women already at increased risk for rheumatoid arthritis who use the IUD may produce antibodies that further heighten that risk, while another study found no increased risk of IUD use at all in women with systemic lupus erythematosus (SLE).
While concerns are valid whenever we are considering using a medical device, and history tells us to be cautious, the current consensus is that the link between IUDs and autoimmune conditions is generally weak, and copper toxicity risks are negligible. However, this may not be your preferred choice for contraception if you:
- already have an autoimmune condition
- have a strong immediate family history of one
- experience undesired side effects from the copper IUD
Instead, you may want to consider a progestin IUD or another form of contraception completely.
Dr. Aviva, Do You Recommend Birth Control Pills?
The Pill is one of the most popular, effective, and convenient forms of birth control available. It offers a 99 percent success rate with “perfect use” and 93% efficacy with typical use. Plus, it’s now possible to get birth control pills at a very low cost or even for free with certain plans and providers, as well as online without the hassle of a doctor’s office visit.
While I do occasionally prescribe the Pill in various forms and doses, I generally only do so when it’s a patient’s preferred choice for contraception, or when needed for treating certain gynecologic conditions. I’ve discussed the potential risks of birth control pills at length before, but here are a few – though not all – facts women should know but often aren’t informed of:
- The Pill has been shown to increase risk of depression – even if you lack a history of depression or mental health issues.
- The Pill is associated with depleting a number of nutrients important for overall health, and healthy moods.
- The Pill can lead to weight gain and insulin resistance, with an overall lifetime increase in the risk of developing diabetes.
- The Pill makes your blood coagulate more, which increases the risk of blood clotting -especially if you have PCOS or are overweight.
- The Pill can disrupt your gut microbiome, which can then lead to a host of additional undesired side effects including digestive issues, acne, and various manifestations of inflammation.
- While the Pill may help clear up acne, breakouts often come back once you discontinue taking it. In women with PCOS, some forms of the Pill may worsen acne (while other forms may be helpful).
- The Pill is correlated with a greater risk of developing certain types of cancer, including breast cancer and cervical cancer. Though to be fair, it’s also correlated with protective effects against colon and ovarian cancers.
- It can take anywhere from six months to two years to resume regular menstrual cycles after you discontinue taking the Pill.
- The Pill can delay fertility, which can pose difficulties if pregnancy is on the radar in your short-term or medium-term family planning.
These risks vary depending on whether the Pill you’re prescribed contains estrogen, or progestins alone, and individual factors. For example, a clotting disorder, migraine with aura, being a smoker, or being over the age of 35 may preclude safe use of various forms of the Pill. Other types of hormonal contraception, including implantable devices such as Nexplanon and insertable options like the NuvaRing, carry similar risks to using the Pill.
All things considered, I’m generally wary about recommending the Pill not only due to potential risks, but also because of the common side effects I’ve mentioned. While I neither disavow hormonal birth control including the Pill nor do I intend to stoke fear around using them, I generally advocate choosing other forms of birth control unless the benefits outweigh the risks for an individual user. In any case, it’s incredibly important to be informed about the general risks and any specific risks that may apply to you based on your own medical history, as well as the signs and symptoms of side effects to look out for.
What Type of Birth Control Is Best for Me?
At the end of the day, choosing the best form of birth control for you is a personal decision that involves the range of diverse factors I’ve discussed. Keep in mind that in addition to medical doctors, nurse practitioners and certified nurse midwives can also provide phenomenal contraceptive counseling and most can prescribe it as well. Each can help you weigh your options to discover the best form of birth control that fits your unique needs. You may also find that what’s best for you now may be different six months or even six years down the road.
If you’re looking for the best form of birth control that’s noninvasive and hormone-free, I typically suggest a combination of condoms and fertility awareness. However, I often prescribe the IUD – whether copper or low-dose hormone-releasing based on a woman’s personal preference and goals – for those who don’t prefer condoms, can’t fully commit to the rigor of fertility awareness methods, or for whom irregular periods make fertility tracking unreliable and difficult.
With that said, birth control is never a one-method-fits-all kind of approach. In summary, choosing birth control requires knowing the options – including their benefits and risks – and developing a clear understanding of your preferences and comfort level with the different options, and then trying that method to make sure it’s the right one for you. You just have to make sure that whatever you choose, you use it according to instructions for the best, safest results!