1. Your cycle
  2. Sex
  3. Birth control

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How to Choose Birth Control: An Interview with Professor Johannes Bitzer, Part 2

Here’s the second part of our interview with Prof. Johannes Bitzer, former president of the European Society of Contraception and one of the leading experts in the field of birth control. We talk about choosing the right method of contraception for yourself, how to store birth control, and when to talk to kids about sexuality and methods of protection.

You can catch up on the first part of the interview here.

“We have information about Ancient Egyptian and Greek cultures,” says Professor Johannes Bitzer. “The basic principle was that people understood pregnancy had something to do with intercourse and the contact between sperm and the vagina. So the first method had to do with putting something into the vagina.”

Ancient Egyptians used to put wool in the vagina. Wool isn’t the only thing they used — there were lots of things they tried, and some of them were pretty unpleasant. This was done to prevent contact between the sperm and the cervix. They had no knowledge of ovulation at the time.

They also had a sort of condom made from sheep’s gut. So they understood they could put something on the penis to prevent sperm from going where they didn’t want it to go.

Johannes Bitzer says that later, in Greece, women were advised to get up after intercourse and jump. According to Bitzer, “Vaginal douching was also probably invented quite early in human history.”

Johannes Bitzer says that there are two primary methods of long-acting reversible contraception: “One is intrauterine devices, either with copper or hormones. The other method is implants — a hormonal stick put under the skin. The implant is effective for about three years, while IUDs last about five to 10 years.”

Professor Johannes Bitzer says that there are permanent, non-reversible birth control options. In the female reproductive system, this involves surgically interrupting the uterine tubes, and in the male system the same is done to the ducts that transport sperm. 

“There are different operations for non-reversible female birth control that are either made through the abdomen or from inside the uterus,” explains Bitzer. “The principle is always the same: you close the uterine tubes so the egg cell and the sperm can’t get together.” 

He also adds that for male permanent contraception, the procedure is now quite simple. “You just make a very small incision, get hold of the duct where the sperm is transported, and close it with a clip.”

Bitzer says there are three options now available as emergency contraception:

  • Progestogen pill — You should take it as soon as possible. It’s most effective during the first 48 hours after unprotected sex.
  • Antiprogesterone pill — This pill is prescribed in many countries under different brand names. It can be taken up to 72 hours after unprotected sex. 
  • IUD — The copper IUD is the most effective form of emergency contraception. It can be inserted up to five days after unprotected sex. Once it’s in place, it offers highly effective birth control for years.

“We have quite a bit of options when people realize the condom broke or if they had intercourse without any protection. In most countries, it’s over the counter — you can go to the pharmacy and don’t necessarily need a prescription from a doctor.”

According to Bitzer, the classic and most-used method is hormonal contraceptives — the pill. 

He also says the pill can actually have some positive effects on teenagers:

  • Very effective protection from pregnancy when taken correctly
  • Cycle regulation
  • Improved complexion, and more

“Basically, the pill is still one of the best methods,” explains Bitzer. “The biggest disadvantage is that you may forget to take it. This is why, in recent years, the long-acting methods I mentioned before have become more popular with teenagers and are more often recommended by professionals. When I was young, the general recommendation was to not use LARC [long-acting reversible contraception] in young females, to not insert an IUD.” 

Now, this has changed, he says: “There is general agreement now that adolescents can use LARCs. But I believe in many countries the pill is still quite popular. It reduces dysmenorrhea and strong bleeding, which many young women have.”

Professor Bitzer believes it’s a good idea to talk to kids about sex when they’re five or six. “As for birth control, I think the conversation about sexuality and contraception should happen as soon as puberty starts.” 

He also adds that schools play a very important role, and good sexuality education is essential. In recent years, the internet has become an important source of information about sex. But there is unfortunately a lot of misinformation on the internet, and it is important to get the facts. Here, doctors play an important role.

“There is no best pill,” says Bitzer. “It really has to be individualized. Fortunately, we have a lot of different preparations with different dosages and ingredients.”

He further explains that some people need a bit more estrogen to prevent irregular bleeding. Some need more progestogen, which is good for the skin but may have a bit higher risk of thromboembolic complications. “You have to really individualize. And I think it’s very important that doctors and health care professionals are well-trained and understand what is inside each pill to individualize the treatment. We call it tailoring contraception.” 

“I think the evolution in this respect is that most of the newer pills have less than a seven-day break,” says Bitzer.

Some pills don’t even have a break. You just continue to take the pills, because you don’t actually need the bleeding. “The break was created just to make the cycle look natural. But menstruation is not that useful: It can even have a considerable negative impact on health,” says Bitzer. “There are tendencies to either reduce pill-free days or make a continuous cycle.”

“There were some interesting studies going on looking into the possibility of very effective male contraception, apart, of course, from the condom,” says Bitzer. “They found that you can almost do the same thing in men — you would give progestogen to suppress sperm production and extra testosterone so they would have enough testosterone. The progestogen is given as an implant and the testosterone as an injection. This combination of implant and injection might work.”

The research is still ongoing, he says, primarily by private research organizations and the National Institutes of Health to a lesser degree.

Professor Bitzer says that there is currently ongoing research on the subject.  Computer scientists and biologists are working together to develop contraceptive methods based on a good data set. “We have new technologies to collect data about all sorts of factors ([body] temperature, menstruation patterns, hormones in urine), from which computer programs can calculate fertile days — the six days before ovulation and one day after ovulation.”

He says people used to use something called the Knaus-Ogino method, which was just counting the days and assuming when ovulation would take place. People who used this method thought that ovulation always occurred two weeks after the first day of a period. To avoid pregnancy, they abstained from sex on days 8–14 of their cycles. But this would only work if ovulation is in the middle of the cycle, and the cycle is 28 days long, which isn’t the case for many people. 

Other methods of detecting the fertile days include tracking basal body temperature or cervical mucus. In recent years, hormonal testing methods have been developed that show the peak of luteinizing hormone in the blood urine to detect ovulation. 

“If you combine all the methods together, it’s quite effective, but it demands a lot of discipline,” says Bitzer. “There are now things like Flo and other apps that collect data. And it may well be that in the future we get more of these programs that would allow women to better understand their cycle, determine their fertile days, and either strictly use a condom on their fertile days or not have sex.”

Professor Bitzer says oral contraceptives — available by prescription in most countries— can be stored at room temperature.

“The only thing you would have to store in a fridge is the vaginal ring, but things like condoms are easy to store.”

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