Welcome back to the Birth Control Series! In our last few posts we’ve discussed the pill; today we’re moving on to other hormonal methods. Click here to access Birth Control Unlocked, your guide to all relevant (to me) birth control information.

The implant, the patch, and the NuvaRing are all hormonal birth control methods.   One is a thin rod implanted into the arm by a medical professional, another is a patch attached to the skin, and the final is a flexible plastic ring inserted into the vagina.  Each of them gets hormones into bloodstream.  The only real difference between these methods and birth control pills is the method of ingestion.  They are marketed as hassle-free birth control methods, and that’s true, more or less.   They require less mindfulness than birth control pills do.  Whether or not that’s something you desire is completely up to you.

Each of the methods varies slightly by use by and by hormonal content.  There are also some specific health concerns related to each method, so they are worth noting.

The Implant

The implant, under the two brand names Implanon and Nexplanon, is a small rod inserted under a woman’s arm.
The implant is made of medical plastic that is sterile and soft. This contraceptive rod is 40mm (1.5 inches) long and 2mm (0.08 inches) in diameter. The implant, once inserted, is effective for a maximum of three years.   The implant is the only of these three methods to be a progesterone-only method.

Once the birth control implant is inserted, it begins releasing small doses of the synthetic progesterone etonogestrel. Implanon contains 68 milligrams of etonogestrel, and it is released slowly and steadily over the course of the three year period.

Since the implant is a continual dosage of a progestin, the implant does not include a regular cycle the way most other birth control methods do.  For the majority of women on the implant, their periods become light but unpredictable.  For 30 percent of women, menstruation stops completely within one year of use.  For this reason, the implant might be a convenient and relatively risk free option.  I call it “relatively” risk free because it is estrogen-free.  It is usually estrogen-based pills–such as the methods below–that have the potential for scary side effects such as thrombosis and heart attacks.

The patch

The patch in the form of Ortho Evra was first released in 2002.   Because of it’s supreme convenience and relatively low cost, it became a best-seller in two short years, selling nearly 400 million dollars worth.

However, Ortho Evra is a progesterone-estrogen combination pill, and it turns out that the patch generated much higher levels of estrogen in the blood of users than pharmaceutical companies had anticipated.  This results in a greater risk of blood clots– and shortly thereafter lawsuits began piling up.   In 2005, Ortho Evra, under an agreement with the FDA, added a black-box warning to its packages stating that patch users are exposed to roughly 60 percent more estrogen than the typical pill user, resulting in a potential “approximate doubling of risk of serious blood clots.

That risk remains fairly low, and there are warning signs that can be heeded in order to save women at risk:

  • a new lump in the breast
  • a sudden very bad headache
  • achy soreness in the leg
  • aura — seeing bright, flashing zigzag lines, usually before a very bad headache
  • bad pain in the abdomen or chest
  • headaches that are different, worse, or happen more often than usual
  • no period after having a period every month
  • trouble breathing
  • yellowing of the skin or eyes
It is also of course known that women with health problems, even ones as common as diabetes or pre-diabetes, should step cautiously around high doses of estrogen.  Risks are low, but the costs are high.
Using the patch

The patch is another birth control method that works in cycles.  The pattern is three weeks on, with one patch applied each week, and then one week off.  The “off” week is when menstruation occurs.

The patch is applied to a woman’s upper outer arm, buttocks, abdomen or thigh on either the first day of her menstrual cycle or on the first Sunday following that day, or for an amenorrheic woman on any random day, whichever is most appropriate for this woman. The day of application is known by the companies from that point on as patch change day. Seven days later, when patch change day comes again, the woman removes the patch and applies another to one of the approved locations on the body. This process is repeated again two more times.  And then one whole 7 day period is taken off for menstruation, starting the whole cycle again on the following patch change day.

Continual use of the patch has been studied, but is not recommended considering the relatively higher estrogen dose of the patch.

All that being said– while higher estrogen levels are associated with risk of cardiovascular problems, women who suffer from low estrogen levels may benefit greatly from estrogen input.  The appropriate amount of estrogen varies by the individual, so it is worth discussing these issues with your doctor if you are interested in how much estrogen you should be (daring to) take.

The NuvaRing

The NuvaRing is a flexible, plastic ring inserted into the vagina each month.  It is inserted by the individual at the start of the menstrual cycle and left for three weeks, and then removed for one week while a withdrawal bleed occurs.  A new ring is then inserted for the following month.

Back-to-back use of the NuvaRing–that is, without a withdrawal bleed–have been studied.  They do not seem to be alarming, though have not been officially approved by any government agencies.   This is presumably because the estrogen levels from the NuvaRing are low enough to tolerate consistent dosages.

The NuvaRing emerged on the market after the birth control patch, and was instantly popular because it offered an easy contraception method without as much risk of blood clots as the patch.   People still leapt up in arms over the NuvaRing, claiming that it had increased side effects, but several statistical analyses have shown that it carries the same risk as other birth control options.

The NuvaRing is also a combination pill, and delivers 120 µg of etonogestrel, a synthetic progesterone, and 15 µg of ethinyl estradiol, a synthetic estrogen, each day of use.

This is less estrogen than both the patch and other combination pills, which makes the NuvaRing desirable with women who have predispositions to estrogen dominance or who have a history of problems with breast tenderness, PMS, nausea, or cramping.   The NuvaRing also has a lower incidence of breakthrough bleeding, despite how low it’s estrogen dosage is.

Many women believe that the NuvaRing is a more gentle form of birth control than others–that it won’t cause hormonal disturbances–because it sits in the vagina, and therefore acts locally, rather than universally in the body.  This supposedly mitigates the side effects.  But I have yet to be able to find any evidence that this is the case.   So far as I can tell, the reason the NuvaRing may have fewer side effects than other methods is simply because it releases a lower dosage of hormones.

All that being said, some researchers argue that third- and fourth-generation contraceptives — including those that contain desogestrel like the NuvaRing — raise the risk of blood clots without adding any benefit.   Third and fourth generation contraceptives contain synthetic estrogens, which may or may not be more problematic than original formulations and bio-identical forms.  No significant statistical evidence, so far as I can tell, exists to support these claims.

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So those are alternative methods of taking hormonal birth control!   The implant contains progesterone only, and reduces menstruation, the patch contains higher levels of estrogen, and the NuvaRing is a late-generation combination pill with as low a dose of hormones in it as possible.   The side effects and risks of each of these methods is approximately the same as oral birth control pills — except perhaps in the case of the patch, and also in the case of late-generation estrogen consumption.

Coming up are IUDs, sponges and condoms, and fertility awareness!   And menopause!

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Also see:

Part I: Birth control pills: How they work, benefits, and risks

Part II: The Drosiprenone Pill Warning

Part III: Which Birth Control Pills are Which?

Birth Control Unlocked: Your Body, Your Options, Your Guide 

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