another sex tutorial

Thinking about birth control is part of thinking about having intercourse. Some people choose to engage only in sexual behaviors other than intercourse -- some because they prefer other forms of intimacy; some because they're not ready for intercourse; and some because they don't want to risk pregnancy.

Choosing a method of birth control isn't always easy. In addition to thinking about the effectiveness, benefits, and possible side-effects of the methods you're considering, you need to think about what you feel comfortable using. It's important to ask yourself what methods realistically fit with your personality and lifestyle.

Talking about birth control with a partner can be hard. It may help to try to sort out your own feelings before you bring up the subject with your partner. Try to find a time and a way to talk about it that feels comfortable to you.

What Do Effectiveness Rates Mean?

A range of effectiveness is listed for each method of birth control in this handout. The lower rating listed is the "typical effectiveness," which takes into account incorrect or inconsistent use. The higher number is the "theoretical effectiveness" rate, which describes the method's effectiveness when used correctly every time a couple has intercourse. Effectiveness statistics are difficult to evaluate because they vary widely depending on the design of the research study. The method with the highest effectiveness rating may or may not be the "best" method for you. The best method is the one which you are informed about, comfortable with, and will use consistently.

Birth Control and Sexually Transmitted Diseases (STDs)

You may be primarily concerned with preventing pregnancy when you choose a method of birth control, but if you or your partner has ever had sexual contact with anyone else, you may be at risk for contracting an STD. Using condoms and spermicide provides the greatest protection against STDs. Other methods of birth control (noted in this handout) may also provide some protection. Many women and men use condoms and spermicide along with other methods of birth control to protect themselves and their partners from STDs.

What If Your Method Fails?

Correct and consistent use of your birth control method makes it less likely to fail; however, no method is perfect. If your method fails, or you have unprotected intercourse, the risk of pregnancy may be reduced by immediately inserting two applications of spermicide into the vagina. Also, call the Gynecology Clinic or Dial-A-Nurse about the availability of the morning-after pill.

METHOD Birth Control Pill EFFECTIVENESS 97-99.9% HOW TO OBTAIN Requires recent gynecological exam and attendance at Birth Control Education Class. Call Gynecology for appointment and class schedule. STD PROTECTION No OTHER CONSIDERATIONS Provides continuous protection. Must be taken at the same time every day. Regulates menstrual cycle, decreases cramps and flow. May cause breakthrough bleeding, breast tenderness, nausea, weight gain/loss during the first few months. Some women are not good candidates because of medical history.

METHOD Norplant (Hormonal Implants) EFFECTIVENESS 99.9% HOW TO OBTAIN Not available at McKinley -- call Gynecology for information. Newly available in 1991. Initial cost $400-$600. STD PROTECTION No OTHER CONSIDERATIONS Requires minor outpatient surgical procedure for insertion and removal. Provides continuous protection for five years (may be removed sooner, if desired). May cause weight gain. Frequently causes irregular bleeding during the first year of use.

METHOD Depo-Provera (DMPA (Hormonal Injections EFFECTIVENESS 99.9% HOW TO OBTAIN Not available at McKinley, call Gynecology for information. Approved for contraception use in 1992. Cost is $25 - $45 per injection. STD PROTECTION No OTHER CONSIDERATIONS A shot every 12 weeks provides continuous protection. Does not contain estrogen. May cause irregular bleeding and spotting, heavier or lighter periods. May cause breast tenderness, nausea, during first few months. May cause weight gain.

METHOD IUD (Intrauterine Device) EFFECTIVENESS 97-99.2% HOW TO OBTAIN Requires 2 appointments for gynecological exam and insertion. STD PROTECTION No OTHER CONSIDERATIONS Provides continuous protection. May cause heavier menstrual bleeding and more severe cramps. Some women are not suitable candidates.

METHOD Diaphragm & Cervical Cap EFFECTIVENESS 82-94% HOW TO OBTAIN Requires recent gynecological exam and may require multiple appointments for fitting STD PROTECTION Some OTHER CONSIDERATIONS Most effective if inserted before any genital contact. Does not affect menstrual cycle. Some women cannot be fitted. Minimal side effects. Some consider it messy or difficult to use.

METHOD Condom EFFECTIVENESS 88-98% HOW TO OBTAIN Can be obtained at Health Resource Centers (locations on back of handout) and at drug stores STD PROTECTION Yes, most effective OTHER CONSIDERATIONS Most effective if put on before any genital contact. Recommended to be used with additional spermicide. May reduce sensation.

METHOD Spermicides (Jelly, foam, cream) EFFECTIVENESS 79-97%

HOW TO OBTAIN Spermicidal jelly is available at Health Resource Centers (locations on back of handout). Other spermicides can be obtained at drug stores. STD PROTECTION Some OTHER CONSIDERATIONS Most effective if inserted before any genital contact. Some consider messy to use. Recommended to be used with a condom. Provides additional lubrication. May cause irritation (switching brands may help)

METHOD Sponge EFFECTIVENESS 82-94% HOW TO OBTAIN Not available at McKinley -- can be obtained at drug stores. Cost is $1 - $2 each. STD PROTECTION Some OTHER CONSIDERATIONS Most effective if inserted before any genital contact. Effective 24 hours. Recommended to be used with a condom. Some consider it messy or difficult to use. May cause itching, irritation. May not fit all women well.

METHOD Fertility Awareness EFFECTIVENESS 80-98% HOW TO OBTAIN Individual instruction about this method is available at Planned Parenthood -- call 359-8022 to schedule an appointment. STD PROTECTION No OTHER CONSIDERATIONS Requires some instruction, high motivation, and diligent record-keeping of fertility indicators. Increases awareness of changes in menstrual cycle. Requires use of back-up method or abstinence from intercourse during fertile part of cycle. Can be an all natural method. Stress, illness, or vaginal infection can affect fertility indicators

A NOTE ABOUT WITHDRAWAL, RHYTHM, AND DOUCHING Withdrawal is a method couples sometimes use. It can fail due to the presence of sperm in pre-ejaculatory fluid, or the couple misjudging when the man should withdraw. This method requires a high level of trust and cooperation, and couples may find it unsatisfying to use. Withdrawing before ejaculation is better than using no method at all. Couples who use the rhythm ("safe time") method abstain from intercourse (or use another form of birth control) during the fertile time in the woman's menstrual cycle. This method can fail because it is possible for a woman to ovulate at any time during her cycle, including while she is menstruating. The Fertility Awareness Method (described briefly in this handout) combines charting of a woman's menstrual cycle with other fertility indicators to provide more complete information about when ovulation occurs.

Douching after intercourse is not an effective form of birth control, because some sperm may reach a woman's uterus almost immediately after ejaculation. In addition, douching may push sperm toward the uterus and increase the likelihood of pregnancy.

Reference: Hatcher, et. al. (1990). Contraceptive Technology, 1990-1992, 15th Revised Edition, New York: Irvington Publishers, Inc.

Copyrighted by the University of Illinois Board of Trustees, 1994

THE DIAPHRAGM

What Is a Diaphragm? -------------------- The diaphragm is a soft, thin rubber cup that is placed in the vagina before intercourse. It is a "barrier" method of contraception, and one of its advantages is minimal side effects. The diaphragm covers the cervix and prevents sperm from entering the uterus. When properly used with spermicidal jelly or cream each time you have intercourse, the diaphragm can be 97% effective. Since women differ in the size and shape of the vagina, diaphragms are made in several sizes and types. The correct size and type can only be determined by a doctor or nurse during a pelvic exam.

When Do I Insert the Diaphragm? ------------------------------ The diaphragm must be inserted before intercourse. If intercourse does not occur within 2 hours, a second application of the spermicide is necessary. The diaphragm should not be removed to do this. Insert the additional jelly or cream with an applicator. An application of spermicide is required each time you have intercourse. Be careful not to dislodge the diaphragm with the applicator. You need:

Diaphragm -- available by prescription at McKinley Health Center pharmacy; comes in its own plastic case.

Spermicidal Jelly or Cream -- available by prescription at McKinley pharmacy; available from both Health Resource Centers; available at other pharmacies for purchase over-the-counter.

Plastic Applicator -- for inserting additional spermicide. Available at McKinley and generally comes inside the spermicide package.

How Do I Insert It? ------------------- Wash your hands before handling the diaphragm. Before insertion, put about 1 tablespoon of spermicidal jelly or cream into the dome of the diaphragm and spread some around the rim. If desired, apply a small amount to the outside of the diaphragm to aid insertion. The diaphragm may be inserted while you are standing, squatting or reclining. (It can also be inserted by your partner.)

First, using the thumb and first 2 fingers, press the rim together so that the diaphragm folds in the middle. With the other hand, spread the vaginal lips. Now, insert the diaphragm into the vaginal canal and gently push the diaphragm along the vaginal floor as far as it will go, to make sure it passes the cervix. The diaphragm will open up once inside; now, tuck the front rim up behind your pubic bone. Check to make sure the cervix is covered! Run your finger over the surface of the diaphragm -- you should feel the cervix behind the diaphragm. If the diaphragm is uncomfortable, remove it and reinsert. Be sure and check the cervix again.

When and How Do I Remove It? ---------------------------- The diaphragm must be left in place 6 - 8 hours after intercourse. To remove the diaphragm, hook your finger under the front rim and gently pull down and out. If you have difficulty with removal, bear down, while squatting, and pull on the diaphragm.

Care of Your Diaphragm: ------------------------ After removing the diaphragm, wash it with a mild soap and water. Rinse it with clean water. Dry carefully. Do not use perfumed soaps containing cold cream or detergents to wash the diaphragm. The elements in these soaps may have a harmful effect on the latex rubber diaphragm.

Dust the diaphragm lightly with cornstarch and replace it in the container. Do not allow the diaphragm to air dry. Do not use any type of body powder, baby powder, flour or face powder, as they may contain elements that could affect the latex rubber diaphragm. Do not use cold cream, Vaseline or other oily substances as a diaphragm lubricant, as these may also be harmful to the diaphragm.

Additional Information: -----------------------

1. If you gain or lose 10 lbs. or more, or become pregnant, the diaphragm should be refitted.

2. If you think you may have sex, you can insert your diaphragm before you go out. Be sure you insert additional jelly with the applicator before intercourse (if more than 2 hours).

3. In the past, women were counseled to only use certain positions during intercourse. There is no evidence to support this. There should be no fear of dislodging the diaphragm if it is fitted and inserted correctly.

THE PILL

Over 10 million women in the United States currently use an oral contraceptive, the pill, to prevent pregnancy. There are a number of different brands available, manufactured by several different companies.

The questions and answers outlined below provide important information to assist you in using the pill in the safest, most effective manner. Be sure to read these directions before you start taking your pills, and any time you are not sure what to do. Please address any questions you have to your medical provider.

How does the pill work? ----------------------- * It prevents ovulation * It alters the cervical mucus, making it less penetrable to sperm It alters the endometrial lining, inhibiting implantation of a fertilized egg, if ovulation has occurred.

How effective is the pill? -------------------------- The pill is 99% effective when taken correctly. If you stop taking the pill, you may become pregnant very soon. Many pregnancies occur when women stop taking their pills and have intercourse without using another method of contraception.

Who should or should not take the pill? --------------------------------------- Each person is evaluated on an individual basis. Determining factors include: past medical history, family history, and findings of a physical exam.

What are the benefits? ----------------------- * decreases blood loss and incidence of iron-deficiency anemia * decreases severity of menstrual cramps * regulates menstrual periods * decreases risk of fibrocystic breasts and ovarian cysts * often improves acne

What are the risks? ------------------- The risks of using the pill are low compared to the risks of pregnancy and childbirth. Nearly all risks are associated with the cardiovascular system. Smoking significantly increases these risks. If you experience any of the following symptoms, you should seek medical care right away and tell the physician you are on the pill:

A - Abdominal pain (severe) C - Chest pain, shortness of breath, coughing up blood H - Headache (severe), numbness or weakness in arms and legs E - Eye problems (vision loss, blurring, or flashing lights) S - Severe leg pain in calf or thigh

What about cancer and the pill? -------------------------------- Since 1960, when birth control pills first became available, important information about pills and cancer has been learned: pills reduce the risk for ovarian cancer; pills reduce the risk for endometrial cancer; most studies suggest that pills neither reduce nor increase risk for breast cancer.

Further research is needed, as there may be a small number of women who are at increased risk for breast cancer. Women are recommended to do breast self-examination every month, and report any changes or problems to their health care provider.

How do I get a pill prescription? ---------------------------------- First-time pill users must attend a birth control education session at McKinley. All pill users must have a pap test done within the year by a McKinley clinician or by a health care provider or clinician. First-time pill users are dispensed three (3) pill packets. Before you finish taking the third packet, return to Pharmacy for refills. If you have any problems, call Gynecology Clinic.

How do I take the pill? ------------------------ Important facts to remember are:

1. (Before you start taking your pills), look at your pack to see if it has 21 or 28 pills. The 21-pill pack has 21 "active" pills to be taken one-a-day for 3 weeks, followed by 1 week without pills. The 28-pill pack has 21 "active" pills to be taken one-a-day for 3 weeks, followed by 1 week of "reminder" pills to be taken one-a-day for 7 days.

2. The right way to take the pill is to take one pill every day at the same time. Establish a regular routine. If you miss pills, you can get pregnant. This includes starting the pack late. The more pills you miss, the more likely you are to get pregnant. Take a pill every day, until you have completed the pill pack.

3. Some women have spotting or light bleeding, breast tenderness, and/or nausea during the first 1-3 packs of pills. If you experience any of these, do not stop taking the pill. For nausea, try taking your pill after meals. All of these symptoms will usually go away. If they don't, check with your health care provider before getting a refill from the pharmacy.

4. If you take a pill more than six hours late, it is considered a missed pill. Varying the time you take your pills may cause spotting or bleeding and increase the risk of pregnancy.

5. If you have vomiting or diarrhea, for any reason, or if you take other prescription medicines, including antibiotics, your pills may not work as well. Use a back-up method (such as condoms, foam, or sponge) if you have intercourse, and check with your health care provider. (See handout titled Oral Contraceptives and Drug Interactions).

6. Your period will probably be shorter and lighter. If you miss a period, and you've taken your pills correctly, you are probably not pregnant. Stay on schedule with your pills and get a pregnancy test to be sure.

7. At the end of your pill pack: If you are on a 21-pill pack, you should wait 7 days to start your next pack. You will probably get your period during that week. Don't wait longer than 7 days to begin your next pack. If you are on a 28-pill pack, you will start a new pack the day after you finish your current pack. Do not wait any days.

WHEN TO START THE FIRST PACK OF PILLS

You have a choice of which day to start taking your first pack of pills. Decide with your health care provider which is the best day for you. Pick a time of day which will be easy to remember.

Day 1 start: ------------ 1. Take the first "active" pill of the first pack during the first 24 hours of your menstrual period.

2. You will not need to use a back-up method of birth control, since you are starting the pill at the beginning of your period.

Sunday start: -------------- 1. Take the first "active" pill of the first pack on the Sunday after your period starts, even if you are still bleeding, If your period begins on Sunday, start the pack that same day.

2. Use another method of birth control as a back-up method if you have intercourse any time from the Sunday you start your first pack until the next Sunday (7 days). Condoms (used with foam or the sponge) are good back-up methods of birth control.

WHAT TO DO IF YOU MISS PILLS

If you miss 1 "active" pill: 1. Take it as soon as you remember. Take the next pill at your regular time. (This may mean you take 2 pills in 1 day.) 2. You do not need to use a back-up method if you have intercourse.

If you miss 2 "active" pills in a row in week 1 or week 2 of your pack: 1. Take 2 pills on the day you remember and 2 pills the next day. 2. Then take 1 pill a day until you finish the pack. Remember, bleeding may occur. 3. If you have intercourse, you must use another birth control method (such as condoms, used with foam or sponge) as a back-up for the next 7 days after you miss the pills.

If you miss 2 "active" pills in a row in week 3 of your pack: 1. If you are a Day 1 Starter -- Throw out the rest of the pill pack and start a new pack that same day. If you are a Sunday Starter -- Keep taking 1 pill every day until Sunday. On Sunday, throw out the rest of the pack and start a new pack of pills that same day. 2. You may not have your period this month, and spotting may occur. However, if you miss your period 2 months in a row, call your health care provider, because you might be pregnant. 3. If you have intercourse, you must use another birth control method (such as condoms, used with foam or sponge) as a back-up for the 7 days after you miss the pills.

If you miss 3 or more "active" pills any time during your pack: 1. If you are a Day 1 Starter -- Throw out the rest of the pill pack and start a new pack that same day. If you are a Sunday Starter -- Keep taking 1 pill every day until Sunday. On Sunday, throw out the rest of the pack and start a new pack of pills that same day. 2. You may not have your period this month, and spotting may occur. However, if you miss your period 2 months in a row, call your health care provider, because you might be pregnant. 3. If you have intercourse, you must use another birth control method (such as condoms, used with foam or sponge) as a back-up for the 7 days after you miss the pills.

If you forget any of your 7 reminder pills in week 4 of your 28-day pill pack:

1. Throw away the pills you missed. Keep taking 1 pill each day until the pack is empty. you do not need to use a back- up method if you have intercourse.

If you are still not sure what to do about the pills you have missed:

Use a back-up method any time you have intercourse. Keep taking one "active" pill each day, and contact your health care provider.

Is there anything else I need to know? ---------------------------------------- The birth control pill does not protect against sexually transmitted diseases. Condoms and spermicide do.

If you are concerned about any difference in your treatment plan and the information in this handout, you are advised to contact your health care provider.

Reference: ---------- Hatcher, R., Guest, F., Stewart, F., Stewart, G., Trussell, J., Bowen, S., & Cates, W. (1989). Contraceptive technology, 14th Revised Edition. New York: Irvington.

HOW TO USE A CONDOM

1. Put the condom on before any genital contact. If uncircumcised, pull back the foreskin.

2. Cover the head of the penis with the condom and gently press the air out of the tip. Unroll it, so that the entire erect penis is covered. A drop of lubricant may also be placed in the tip of the condom before unrolling it onto the penis.

3. If needed, you may generously apply a water-based lubricant to the outside of the condom before penetration. Do not use oil-based lubricants.

4. To prevent slippage, hold the condom at the base of the penis whenever withdrawing.

5. If ejaculation occurs, withdraw the penis before it gets soft. Hold onto the condom to prevent slippage. Throw the condom away.

HOW TO USE SPERMICIDAL JELLY

1. For vaginal intercourse: insert spermicide before any genital contact and repeat application if more than 15 minutes passes before intercourse.

Fill the applicator completely by attaching to the tube and squeezing. Insert the applicator deep into the vagina and push the plunger completely into the applicator. Use an additional application of jelly if intercourse is repeated. Do not douche for eight hours after intercourse.

2. For anal intercourse: if spermicidal lubricant is used, it should be applied to the outside of the condom prior to penetration.

Even if you use a lubricated condom, the use of additional lubrication can increase pleasurable sensations and help prevent tearing of the condom. Lubricants or spermicides containing nonoxynol-9 can provide extra protection because this chemical kills many STD (sexually transmitted disease) germs.

STDs can be passed during vaginal, oral and anal sex. If you are using a condom for oral sex, you may prefer to use a non-lubricated or flavored condom. A condom can be cut to form a latex square for use as a barrier during cunnilingus or during oral-anal contact.

If a condom breaks, immediate withdrawal is recommended. A new condom can then be used. To reduce the risk of pregnancy, a woman can immediately insert two applications of spermicide into the vagina.

THINGS TO REMEMBER

Latex condoms are recommended for best STD protection.

Proper usage can increase a condom's protection. Avoid sharp objects, fingernails, and air bubbles. Be sure there is plenty of lubrication.

Store condoms in a cool place.

Plan ahead and be prepared.

Learn the facts about how HIV and other STDs are spread.

Learn about how to talk with your partner about safer sex.

Alcohol and other drugs lower inhibitions, seriously affect judgment, and lead to unsafe sex.

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