OD-ing on contraceptive pills

Sadia (her name and some others in this article have been changed), 24, while preparing for her upcoming wedding was also worrying about something else—what form of birth control to use. She had been warned by her aunt against using oral contraceptive pills because of the side-effects—that she would gain weight, experience hot flashes. Sadia herself was particularly worried about the hormonal changes due to the pill. Ahead of her wedding, she chose instead to stock up on emergency pills.

She used the emergency pill twice. Sadia, who just completed her Master's studies, didn't visit a gynecologist until after her wedding (then too, for other reasons). She and her husband used condoms and she also had the emergency pill as backup. While at the gynecologist, on revealing that she had taken emergency contraception a few times, she was advised to take oral contraceptive pills as regular birth control. Her fears about side effects were brushed off—she was told pills are much improved now."I was not informed of any long-acting methods or any non-hormonal contraceptive options," she states.

Gynecologists I spoke to say their patients prefer to go for short-acting methods of birth control—condoms, oral contraceptive pills and injections. Dr Jahanara Rahman, a gynecologist practicing at National Medical College, says that even though many modern methods are available now, her patients tend to go for the oral contraceptive pill. It's readily available, widely known, and relatively easy to use—you just need to remember to take it every day, at the same time. Forget to take it once and you are not protected against pregnancy unless you take it alongside a barrier method such as condoms.

According to Dr Rahman, as young women become more aware of options other than the pill, demand for injections, for one, is rising."Patients nowadays are more aware and come to us with their method of choice, compared to earlier. But they still prefer the pill over any other method," says Dr Sharmin Hafeez, a gynecologist who runs a private practice in Paltan. For those who do come to learn their options, especially newly married women, she recommends the minipill (progestin-only birth control pill) over the combined oral contraceptive pill, as the latter presents more side effects.

Side effects include mood swings, nausea and headaches, which tend to go away after a few months. There are positive side effects too—it helps those who experience heavy or painful periods and many find that their skin clears up on using hormonal contraception. However, there is no evidence to support the common perception that the pill makes women gain weight.

Hesitant to use the daily pill, some such as Sadia are using emergency pills instead only as and when they need it."I have observed that many young women take the emergency pill as their only form of birth control. They feel it a burden to take a daily pill or any long-acting methods," says Dr Rahman. But they are relying on a method not meant to act as a regular form of birth control but, as its name suggests, is only meant to be used in the case of an emergency (such as if regular birth control fails or if they were made to have sex against their will).

Professor Dr Ferdous Mahal, head of the Gynaecology and Obstetrics Department at International Medical College Hospital in Tongi, remarks on this practice, "I would not recommend using only emergency contraceptive pills as a form of birth control. It has lots of side effects, much more so than the daily pill."Dr Hafeez agrees, "It's not for regular use. I would advise anyone taking emergency pills to not use these any more than twice a month."

These side effects, though not long-term or serious, can include headaches, nausea and vomiting, unexpected or heavy menstruation. The emergency pills ideally taken as soon as possible after unprotected sex, it becomes less effective the longer you wait to take it. It can be effective for up to five days after, though the exact effectiveness is difficult to measure.

Tasneem, a 27-year-old professional working in development, has also used the emergency pill on occasion, up to three times last year. She first started using birth control years ago, being prescribed oral contraceptive pills for heavy menstruation. But, Tasneem found that she would get depressed and, an oft-stated complaint about the method, forget to take the pill on time every day.

As she could not rely on the oral contraceptive pill, when she was sexually active she turned instead to the morning after pill, as it is commonly known. "It is easier to take one pill right afterwards than taking the [daily] pill regularly," says Tasneem. She was aware of it asa backup to prevent unintended pregnancy, stating however that she is not aware of the potential side effects and does not remember experiencing any of these.

Tasneem knows emergency pills are not a form of birth control, which is why she is now thinking of using a long-acting method. Sadia, almost a year into her marriage, says she will soon adopt such a method too. "We encourage long-term methods as they are more effective at preventing pregnancy and are less hassle than taking a pill every day or an injection every few months," says Rahman.

Thinking long-term

Long-acting reversible contraception such as implants and IUDs (intrauterine device, also known as the contraceptive coil) are more effective at preventing unintended pregnancy but are not as popular as the pill. The copper IUD, a small device placed in the uterus and can last up to 12 years, in particular is touted as the most effective method of birth control out there. It can be taken out at any time and you don't need to think about it once it's been fitted."This is commonly used by women who have already conceived and don't want any more children for now. They can have it removed later, if necessary," says Dr Hafeez. But what is holding back young women getting started with birth control from accessing this option?

"Young women worry about whether they will have problems conceiving later on if they adopt such long-acting methods," says Dr Hafeez. "There are some side effects once the IUD is inserted—there is often heavy bleeding in the months after [copper IUD] or menstruation can stop altogether [hormonal IUD]." But not all women experience these side effects and any harm to the uterus is rare.

According to Professor Laila Arjumand Banu, president of the Obstetrical and Gynecological Society of Bangladesh, "Earlier, the IUD was quite popular in our country. But then untrained nurses and paramedics inserting it incorrectly led to infections and other complications," adding that they have properly trained doctors on the benefits and insertion of IUDs. "These risks are remote possibilities and should not deter patients from going for IUDs. If doctors do it themselves, patients will gain more confidence in the procedure."

But the IUD remains unavailable for young women who are unmarried and/or childless. It has become a common practice among doctors here to reject patients requesting an IUD if they haven't yet undergone childbirth. "It's more or less official protocol," says Dr Rahman. Dr Banu echoes this, stating, "We do not give IUDs to those who are childless. There is a risk of subclinical infection and the [fallopian] tube can close. This is a remote possibility but with potentially devastating consequences for those who have never had children before."

Until quite recently worldwide, IUDs were recommended only for women who have already had a baby. With doctors' refusal to perform the procedure and patient misconceptions about safety, IUDs are not an option for some and not in the radar of others as an option. Instead, young women are overwhelmingly choosing short-acting methods. Short-acting methods can be almost as effective as long-acting methods, but only if correctly used.

Today, even an app has been dubbed a natural contraceptive—Natural Cycles, developed by a Swedish inventor, uses body temperature to help users know how to prevent (or plan) pregnancy. More commonly, period-tracker apps such as Clue and Flo can help young women understand their natural cycles better. An alarm on your phone can remind you to take your daily pill or when your next injection is.

But use of long-acting methods are slowly increasing, says Dr Banu. Modern day contraception is such that young women's options should not be limited to the daily pill and they should not have to resort to taking emergency pills as a form of birth control.