Birth Control Behavioral Methods

The practice of birth control or preventing pregnancy is as old as human existence. For centuries, humans have relied upon their imagination to avoid pregnancy. With no method of birth control during sexual intercourse, a woman of childbearing age with normal fertility has an 85% chance of becoming pregnant in 1 year. 
 
Behavioral methods that don’t use hormones such as birth control pills or mechanical devices such as condoms are in use throughout the world, especially in underdeveloped nations. They often have high failure rates, meaning they don’t work effectively and women become pregnant.

Continuous abstinence is completely refraining from sexual intercourse. There are no hormonal side effects, and abstinence is endorsed by many religious groups.
 
It is 100% effective in preventing pregnancy, and it also prevents sexually transmitted diseases (STDs). Women who are abstinent until their 20s and have few partners are less likely to get STDs, become infertile, or develop cervical cancer. Abstinence costs nothing.
 
Abstinence may be difficult for some couples to maintain. It is important to discuss this decision with your partner before sexual situations arise.

Coitus interruptus involves withdrawal of the entire penis from the vagina before the man ejaculates (before sperm leaves the penis). Fertilization is prevented because sperm does not contact a woman’s egg. This method remains a significant means of fertility control in less advantaged countries.
 

• How effective: This depends largely on the man's capability to withdraw prior to ejaculation. The failure rate is estimated to be about 4% in the first year of using this method exactly. In typical use, the rate is more like 19% during the first year of use. The failure rate means this method does not work to prevent pregnancy, and some couples using it will become pregnant anyway. The higher the failure rate, the more likely a woman is to have an unintended pregnancy. 
  
  
• Advantages: This method can be used at any time, with no devices, no cost, does not involve chemicals or hormones, and may offer a lower risk for other problems. 
  
  
• Disadvantages: There is a high risk for unintended pregnancy. This method does not protect against sexually transmitted diseases (STDs).

Natural Family Planning (NFP), endorsed by the Couple to Couple League, is one of the most widely used methods of fertility regulation, particularly for those whose religious or cultural beliefs do not permit devices or drugs for birth control. This method involves periodic abstinence (no sexual intercourse), with couples attempting to avoid intercourse during a woman's fertile period—around the time of ovulation. (Ovulation is the process in which during a woman's menstrual cycle, one of the woman's ovaries releases an egg.)

The current method of NFP taught by the Couple to Couple League and many other teaching organizations is the symptothermal method. Women who use this method keep track of their cervical mucus signs, their waking temperature (basal body temperature), and their own cycle history. They may also monitor physical changes in the cervix. This method breaks a woman's cycle into 3 phases. Phase I is preovulation infertility, beginning with the first day of menstruation. Phase II is the fertile period, in which conception could occur. Phase III is infertility after ovulation. It is best used by women who have consistent and regular menstrual cycles.

• The symptothermal method determines the first day of no sexual activity based on number of days since the first day of the menstrual period (usually 7) or the first day mucus is detected, whichever is noted first. The end of the fertile period (Phase II) is determined based on basal body temperature (body temperature at rest first thing in the morning, before getting out of bed). The basal body temperature of a woman is relatively low during the follicular phase (first half of her menstrual cycle) and rises in the luteal phase of the menstrual cycle in response so the thermogenic effect of progesterone (the second half leading up to her menstrual period beginning). The rise in temperature can vary from 0.2-0.5° C. The higher temperatures begin 1-2 days after ovulation and correspond to the rising level of progesterone. Intercourse can resume 3 days after the temperature rise. A basal body temperature chart can be obtained from 4women.gov.   
  
  
• To monitor cervical mucus, the woman examines her cervical mucus with her fingers. Under the influence of estrogen, the mucus increases in quantity and becomes progressively more stretchy and abundant until a peak day is reached. This is followed by scant and dry mucus because of the influence of progesterone, which remains until the onset of her period. Intercourse is allowed 4 days after the maximal cervical mucus, coinciding with the rise in temperature, until menstruation.   

NFP has advantages and disadvantages: 

• How effective: The Couple to Couple League states, "the Sympto-Thermal Method of Natural Family Planning can be used at the 99% level of effectiveness in avoiding pregnancy." (See the complete article.) If a couple takes chances and has intercourse during Phase II, the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the U.S. Food and Drug Administration (FDA) reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular methods of periodic abstinence. The American College of Obstetricians and Gynecologists (ACOG) lists a higher failure rate for periodic abstinence of 25%. Again, this figure does not differentiate for type of periodic abstinence.
  
  
• Advantages: No harmful effects from hormone use occur. This may be the only method acceptable to couples for cultural or religious reasons. NFP methods can also be used to achieve pregnancy.   
  
  
• Disadvantages: This is most suitable for women with regular and predictable menstrual cycles. Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. To use this method effectively, a woman or couple should be trained by a medical professional or a qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

Women who use the Fertility Awareness Method (FAM) monitor body temperature and cervical signs of pregnancy similarly to those who practice NFP. However, women using FAM may either avoid intercourse or use a backup nonhormonal method of birth control, such as a condom, during the fertile period.

Women using FAM monitor 3 primary fertility signs: basal body (waking) temperature, cervical fluid, and cervical position.

Basal body temperature before ovulation is considered to range from 97-97.5°F. After ovulation, temperatures rise to about 97.6-98.6°F and stay elevated until a woman’s next period, about 12-16 days later. Temperatures usually rise within a day or so after ovulation, so the rise in temperature generally means that ovulation has already occurred. A basal body temperature chart can be obtained from 4women.gov.

Cervical fluid qualities are also charted throughout a woman’s cycle. Cervical fluid qualities aside from during the menstrual period are designated as nothing/dry, sticky, creamy, or eggwhite. A woman is most fertile when her cervical fluid is like a raw eggwhite. During this time, cervical fluid is clear and stretchy.

The cervix becomes softer and opens around ovulation so that the sperm can pass through the uterus and to the fallopian tubes. The cervix also rises during this time during because of the effects of estrogen on the ligaments that hold your uterus in place.

For maximum effectiveness, FAM users follow 4 rules:

1. Intercourse is allowed in the first 5 days of the menstrual cycle (beginning with the first day of your period) if you had an obvious temperature shift 12-16 days before.
   
   
2. Before ovulation, intercourse is allowed the evening of every dry cervical fluid day.
   
   
3. Intercourse can resume the evening of the third consecutive day your temperature rises to postovulatory levels.
   
   
4. Intercourse can resume the evening of the fourth consecutive day after your peak cervical fluid day.

Intercourse is not considered "safe" for avoiding pregnancy unless all of these rules are met. It is recommended that 2 full cycles be charted before relying on this method.

FAM has advantages and disadvantages.

• How effective: If a couple takes chances and has intercourse without backup protection during the fertile period, their odds of pregnancy increase dramatically. In August, 2002, the FDA reported a failure rate of 20 pregnancies per 100 women per year for periodic abstinence. This figure did not differentiate for particular types of periodic abstinence. ACOG lists a higher failure rate for periodic abstinence of 25%. Again, this figure did not differentiate for method of periodic abstinence. 
  
  
• Advantages: No harmful effects from hormone use occur. FAM methods can also be used to achieve pregnancy. 
  
  
• Disadvantages: Complete abstinence is necessary during the fertile period. This method requires discipline and systematic charting. The method is not effective with improper use. For maximal effectiveness, a woman or couple should be trained by a medical professional or qualified counselor. A relatively high failure rate has been reported. This method does not protect against STDs.

Several other methods of periodic abstinence exist.

• Rhythm method: Couples who practice the rhythm method, also called the calendar method, decide when to abstain from intercourse based on calendar calculations of the past 6 menstrual cycles. However, allowances are not made for the normal variations in the menstrual cycle that many women experience. This method is not as reliable as the symptothermal method of NFP or FAM.
  
  
• Cervical mucus method: Also called the ovulation method, the cervical mucus method involves monitoring cervical mucus only, without also recording basal body temperature or menstrual history. The safe period is considered to be any dry mucus days just after menstruation and the 10 or 11 days at the end of the cycle. Days of menstrual bleeding are deemed infertile; however, pregnancy can occur during menstruation. Vaginal infections, sexual excitement, lubricants, and certain medications can significantly affect the accuracy of cervical mucus assessment.
  
  
• Basal body temperature method: This method involves monitoring basal body temperature only, without also recording cervical mucus or other signs. Sex is avoided from the end of the menstrual period until 3 days after the increase in temperature.

After the birth of a child, certain hormones prevent a woman from ovulating and releasing eggs if she is breastfeeding. The length of time hormones are suppressed varies. It depends on how often the woman breastfeeds and the length of time since the baby’s birth. Ovulation usually returns after 6 months despite continuous nursing. 

Breastfeeding used for birth control is also called the lactational amenorrhea method (LAM), meaning breastfeeding prevents your body from producing the hormones that cause ovulation (release of an egg) and a return to fertility. Some women feel this is an adequate form of birth control. ACOG states, "Exclusive breastfeeding helps prevent pregnancy for the first 6 months after delivery, but should be relied on only temporarily and when it meets carefully observed criteria of the lactational amenorrhea method (LAM)." 

ACOG recommends that for best impact on fertility, women should breastfeed at least every 4 hours during the day and every 6 hours at night. Any feedings the infant is given aside from breastfeeding should not be more than 5-10% of the total the child consumes. For instance, one formula feeding out of every 10 might increase the chance of fertility returning. If this schedule cannot be followed, consider using an additional form of birth control. When the menstrual period returns after pregnancy, another form of birth control is needed.

• How effective:  ACOG reports this method to be 98% effective in the first 6 months after delivery if the above criteria are met. Once menstrual bleeding resumes, the risk of pregnancy increases greatly.
   
• Advantages: A woman has no periods during this time.   
  
  
• Disadvantages: When a woman is fertile again is uncertain. Frequent breastfeeding may be inconvenient. This method should not be used if the mother is HIV positive. This method does not protect against STDs.

Douching is a method of rinsing out the vagina. Women use water or vinegar or solutions purchased at a drug store and spray these solutions into the vagina with a bottle or tubing. It has long been thought that women need to clean their vaginas and reduce odor. Some women douche after their menstrual periods or after sex to avoid getting an STD. Some think douching after sex will prevent pregnancy.

• Douching is not recommended. Douching changes the delicate chemical balance in the vagina and may allow an infection to grow or spread an infection into other pelvic organs such as the uterus. This method does not protect against STDs. It may actually increase the chance of developing pelvic inflammatory disease and transmitting sexually transmitted diseases.
  
  
• Douching after sex does not prevent pregnancy.  In fact, the practice can increase a woman’s chance for developing an ectopic pregnancy, a serious condition that can be life threatening, by causing an infection in the reproductive organs.

|Web Links|

Food and Drug Administration, What Kind of Birth Control is Best for You? 
 
Food and Drug Administration, Birth Control Guide 
 
Planned Parenthood, Facts about Birth Control 

Birth Control Methods 

Planned Parenthood, Is Abstinence Right for You Now?

The Couple to Couple League for Natural Family Planning 

Healthy Pregnancy, Fertility Awareness and Infertility 

American College of Obstetricians and Gynecologists, Contraception While Breastfeeding 

American College of Obstetricians and Gynecologists, Natural Family Planning 

contraception, impregnation, pregnancy, preventing pregnancy, Natural Family Planning, NFP, Fertility Awareness Method, FAM, rhythm method, calendar method, coitus interruptus, withdrawal, abstinence, periodic abstinence, cervical mucus method, ovulation method, symptothermal method, sympto-thermal method, breastfeeding, lactational amenorrhea method, LAM, birth control overview, birth control behavioral methods

Author: Omnia M Samra, MD, Clinical Instructor, Department of Obstetrics and Gynecology, Medical College of Pennsylvania/Hahnemann University.

Editors: Bryan D Cowan, MD, Director, Division of Reproductive Endocrinology, Professor, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Lee P Shulman, MD, Professor of Obstetrics and Gynecology, Head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.