Hormone-free contraception: alternatives to the pill – SWR2

About five times a week, the gynecologist Helga Schwarz advises people at pro familia in Munich who want to know what alternatives there are to the pill. The interest in alternative contraceptive methods has increased significantly in the past two years, says the gynecologist.

Copper spiral, copper chain, copper ball: the right size is important

For women there is mechanical contraception – condoms, diaphragms – and natural family planning. In addition to the conventional copper spiral, there is the copper chain and the copper ball. To explain the differences, Helga Schwarz shows two small plastic models of the uterus. It is important with the copper spiral that a suitable size is selected and that the practice that carries out the procedure does not just use one size fits all. Because if there is irritation on the uterine wall, then it can lead to heavier bleeding.

Pearl index for copper spiral is below 1

All copper-containing contraceptive systems are very safe, says gynecologist Helga Schwarz. And then she names him „Pearl-Index“. It is “below 1”, a value comparable to that of the pill. The Pearl Index indicates the safety of a contraceptive. The lower it is, the safer it is. “Less than 1” means: Out of 100 women who used the copper IUD for a year, fewer than one became pregnant.

The copper spirals are very rarely shed, Helga Schwarz reassures, studies have shown that. When it comes to the question of which model to choose, the condition of the uterus plays an important role. But also the price. A copper spiral costs 25 euros, the copper chain is about five times as expensive.

More and more couples are questioning hormonal contraception with the pill or hormone spiral. They exchange views on internet forums and social networks about the sometimes massive side effects of hormonal contraception: physical complaints such as weight gain, nausea or headaches or psychological stress such as panic attacks or depression.

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Some new birth control pills increase risk of thrombosis and pulmonary embolism

The most serious, although rare, complications from the pill include thrombosis and pulmonary embolism. According to a study by the European Medicines Agency EMA in 2013, the risk of thrombosis and pulmonary embolism with some new third- and fourth-generation pills is one and a half to twice as high as with the older pills.

In its representative studies, the Federal Center for Health Education in Cologne examines how Germans use contraception and whether their behavior is changing. Comparing the data from 2003, 2007, 2011 and 2018 shows a clear trend. While the pill remains the most important form of contraception among 18- to 49-year-olds, its popularity is declining. At the same time, couples are increasingly using condoms.

dr Petra Frank-Herrmann from the Heidelberg University Women’s Clinic confirms the growing interest in alternative contraceptive methods. And on the part of the doctors. The gynecologist has been researching “natural family planning” for years – a contraceptive method that aims to identify the fertile days. She often gives lectures at gynecology congresses and offers further training, her seminars are well attended. That wasn’t the case ten years ago, she recalls.

Natural family planning: dealing with your own body is important

“Natural Family Planning”, or NFP for short, was developed in the 1980s. Its protected name is “Sensiplan”. Basically, this method builds on women learning to recognize their fertile days. To do this, they have to observe their body and notice changes: an increased body temperature, pain in the breasts, a viscous discharge from the vagina, possibly a greater desire for sex.

In natural family planning, body signs and signals that change over the course of the cycle are observed. The women learn to evaluate these signals according to certain rules, so that they then know exactly when they can get pregnant and when not. These signals are the morning waking temperature and a secretion that can be observed at the vaginal entrance during the fertile period.

In a long-term international study, the Heidelberg gynecologist Petra Frank-Herrmann proved back in 2007 that the contraceptive reliability of the NFP method is high, even comparable to the contraceptive reliability of the pill. The only requirement: the woman has to deal with her body in detail and measure and record her temperature regularly. And you should not rely on hasty forecasts from NFP apps, but solely on your own evaluation.

Women often feel pressured to take the pill

But younger women in particular often feel pressured by their gynecologists to take the pill. Pro-familia consultant Helga Schwarz suspects that the reason is the lack of time in everyday practice, because it takes one hour of consultation time to explain the NFP. It is similar with the diaphragm. Doctor Schwarz therefore practices the practical insertion with the women she advises until it fits.

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Diaphragm: without side effects, but less effective as a contraceptive

The diaphragm is a so-called barrier method. It looks a bit like an oversized unrolled condom and consists of a silicone hat with a tight ring around it. It is inserted into the vagina and placed in front of the cervix. The diaphragm prevents – similar to a condom – that sperm cells can penetrate to the egg cell. If a few sperm make it and fight their way through, the second hurdle follows: a sperm-inhibiting gel.

This combination of diaphragm and gel makes the cervix inaccessible to sperm. The method has a pearl index of 2 to 20 and is therefore less reliable than a copper spiral. The advantage: the diaphragm has no side effects. But it should be noted that the sperm-inhibiting gel only works for a maximum of two hours. The diaphragm, which can be used for up to two years, costs 40 euros, and the sperm-killing gel costs ten euros.

According to initial studies, the Pearl Index for the pill for men is 1.5

In the past, contraception was often the sole responsibility of women. Today, the women’s partners also come to doctor Helga Schwarz’s consultation hours. But there is still no “pill for men”.

A promising WHO study started in 2009: 320 study participants were given hormone injections over a period of several weeks. With regard to contraception, the results were promising, the Pearl Index was 1.5 – almost as good as the birth control pill.

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Nevertheless, the WHO study was stopped in 2011 after only two years: almost half of the men had complained about side effects. They suffered from acne and mood swings, along with injection site pain, increased or decreased libido, headaches, muscle aches and weight gain, to name just a few symptoms. – Aren’t these all the side effects that women experience with hormonal contraception?

Despite successes, Germany is ending research on male contraception

Andrologist Eberhard Nieschlag, former director of the Institute for Reproductive Medicine at the University Hospital in Münster, believes that it is time for men to fight for their birth control rights.

Above all, Eberhard Nieschlag criticizes that although there are good approaches to male contraception, nobody in Germany is developing them further. The pharmaceutical company Schering had had good success with a combination of implants and injections in men. But after the pharmaceutical company Bayer bought Schering in 2006, research on it was stopped. One thing, however, cannot be changed: the question of an alternative to the birth control pill will be asked more and more frequently in the future.

SWR 2020

manuscript for the broadcast

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