the future of contraception

by Frances Perrow

Contraception has come a long way since 1921, when Dr Marie Stopes opened the UK's first family planning clinic. Methods then included studs to 'close' the penis or hefty rubber condoms. Women's options included unproven methods such as 'sitting upright the moment after ejaculation has taken place and coughing violently'.

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Dr Stopes was worried about some chemical vaginal douches around at the time, and declared: 'Never put anything in your vagina that you would not put in your mouth!'

In 1958, scientists developed synthetic hormones to block ovulation. These form the basis of many current contraceptives, such as the pill – and those of the future.

Today around 630 million couples worldwide use family planning, including hormonal contraceptives, barrier methods (male and female condoms or caps), intrauterine devices (coils) or sterilisation. But by 2010 there should be more choice.

pills, patches and progestogen

The hormones in contraceptives – oestrogens and progestogens – are very similar to those found naturally in a woman's body. They are the same hormones used for hormone replacement therapy (HRT) for the menopause, but HRT contains different doses of the hormones. So, in a way, the hormones used for contraception are 'natural'. But because they are synthesised in a pharmaceutical factory, and given in the form of pills, they may also cause side effects that wouldn't occur naturally.

There is a long list of possible side effects associated with the contraceptive pill and other hormonal contraceptives – blood clots, increased cancer risks and weight gain are just a few. But when the risks and the benefits are all put together, most experts think that the pill does more good than harm.

New things are on the contraceptive horizon. A new pill on trial in the USA, Seasonale, will result in just four periods a year – you take the pill every day for 84 days before having a one-week break. In fact, Seasonale is just a new way of taking a combination of hormones that has been on the market for years. Clinical trials are now underway to make sure it is safe to only have one period every three months. Seasonale is expected to be on the market in two or three years.

A new generation of progestogens in other pills will reduce some of the side effects, including weight gain.

But the days of daily pill-taking could be numbered. Women have been using skin patches for HRT for years but only now has it become available for contraception. American pharmaceutical company Johnson & Johnson have developed the world's first contraceptive skin patch called Ortho Evra (or in technical speak: the norelgestromin/ethinyl estradiol transdermal system). The thin, beige patch can be worn anywhere on the buttocks, abdomen, upper torso, front and back, (excluding the breasts, or upper outer arm) for one week at a time, and is replaced on the same day of the week for three consecutive weeks.

Launched in the US in April 2002, the patch has fast become one of the most popular forms of contraception among American women. Recently approved by Canadian and European regulatory bodies, Ortho Evra should be available in the UK soon – and may even be followed by a patch for emergency contraception.

Another new way of taking contraceptive hormones – a vaginal ring designed to fit near the cervix and stay in position for a month – will be available within the next year or two. The manufacturers claim that it is comfortable enough to leave in even during sex. But if for any reason you want to take the ring out, it will still be effective as a contraceptive as long as you don't take it out for more than two hours.

just spray it on

By the end of the decade, it is possible that contraceptive gels and inhalers will be available to replace today's pills. So-called 'smart' hormones will also be developed to target the specific parts of the organs involved in fertility. They would make our current range of oestrogens and progestogens, which act on the entire body, look like dinosaur technology.

But all of these new technologies are still in the early stages of development and no one yet knows if they are going to turn out to be as safe and effective as the tried and tested pills we use today.

The three-monthly contraceptive injection – Depo-Provera – has been around for a long time, but many women don't like it because it often causes an irregular bleeding pattern. And the problem with a long-lasting injection is that once it is inside the body, it can't be taken out – you just have to wait until it wears off after about three months.

New injectable contraceptives are being developed to overcome these problems. An injection using a combination of oestrogen and progestogen, Lunelle, is now available in the USA. It overcomes irregular bleeding caused by the current progestogen-only injections, but it has to be injected every month. Its hormone profile is very similar to contraceptive pills. The only difference is that you don't have to remember to take it every morning (although you do have to remember to have an injection every month). Lunelle is not yet licensed in the UK.

Another way of delivering contraceptive hormones is by inserting a tiny hormone-containing rod under the skin. Norplant, the first contraceptive rod (actually it consisted of six tiny rods) was withdrawn from the market because of all the problems that it caused. Implanon, a one-rod version, is now available in the UK, and a new two-rod version of Norplant called Jadelle may be available soon. Both are inserted under the skin. Implanon lasts for three years and Jadelle lasts for five years, although they can be removed earlier.

one for the boys

Scientists have been working on a pill for men for years, but it has proven difficult to find something that stops sperm without also stopping men's sex drive. The latest idea is to combine a pill with an implant and an injection. This is claimed to kill sperm without also killing erections. No one is yet sure how many men will be prepared to take a pill and have an implant and an injection.

Even condoms are soon going to be available in new shapes and with new smells. The eZ-ON, a roomy American condom, pulls on like a sock, can be worn either way out, and offers greater stimulation for couples. Durex latex condoms will soon be available with an odour-mask to eliminate that tell-tale smell of rubber, while a Japanese company has developed a pair of latex underpants with a built-in condom facility, which could be used by men or women to protect against STIs as well as pregnancy.

surgery-free sterilisation

Sterilisation – for both men and women – is still the world's most popular method of contraception, offering a permanent solution. Non-surgical techniques are being explored, including the Selective Tubal Occlusion Procedure (STOP), in which two titanium coils are inserted through the cervix to block the fallopian tubes. The advantage of STOP is that it doesn't require an operation. But like traditional forms of contraception, it is not easily reversible.

For men, work is going on to develop an injection of silicone to block the sperm-carrying vas deferens tubes. This could make it possible to have a vasectomy without having an operation. Again, it would be difficult to reverse, and there are worries about the safety of silicone injections.

more choice by 2010

Mifepristone ('the abortion pill') could become a once-a-month pill, taken at the time of ovulation to disrupt the fertilisation process, if it has already begun.

Work is currently being done on microbicides to kill sexually transmitted infections, including HIV/AIDS, with the future potential to zap sperm as well. Microbicides could be available in vaginal creams or gels, or slow-release rings or pessaries.

Beyond 2010, there is a possibility that women could be vaccinated against pregnancy.

Meanwhile, individual scientists continue to come up with less user-friendly ideas. These include tight latex male 'hot pants', originally from Egypt, to heat the testicles to halt sperm production and an American battery-powered device for insertion in the scrotum to zap sperm. The choice is yours!

help and info

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organisations

Marie Stopes International
153-157 Cleveland Street
London W1T 6QW
Marie Stopes One Call: 0845 300 8090
Website: www.mariestopes.org.uk
Runs a range of reproductive health services including contraception, abortion counselling, well women screening, gynaecological consultations, vasectomy, and psychosexual and relationship counselling.

British Pregnancy Advisory Service (BPAS)
Austy Manor
Wootton Wawen
Solihull B95 6BX
Actionline: 08457 30 40 30 (Mon-Fri 8am-9pm, Sat 8.30am-6pm, Sun 9.30am-2.30pm)
Website: www.bpas.org
Provides affordable services to those who wish to prevent an unplanned pregnancy with contraception, or end one by abortion. Offers pregnancy testing, crisis pregnancy counselling, abortion care, after abortion support, sterilisation and vasectomy and emergency contraception. Website contains information for women thinking about having an abortion, information about emergency contraception, pregnancy testing and what to do next.

Brook
421 Highgate Studios
53-79 Highgate Road
London NW5 1TL
Helpline: 0800 0185 023 (Mon-Fri 9am-5pm)
E-mail: admin@brookcentres.org.uk
Website: www.brook.org.uk
Provides free and confidential sexual health advice and contraception for anyone under 25. The website has tons of useful information including a secure on-line enquiry service and a text messaging service.

fpa
2-12 Pentonville Road
London N1 9FP
Helpline: 0845 310 1334 (Mon-Fri 9am-6pm)
fpa Scotland: 0141 576 5088 (Mon-Thurs 9am-5pm; Fri 9am-4.30pm)
fpa Northern Ireland: 028 90 325 488 (Mon-Thurs 9am-5pm; Fri 9am-4.30pm)
Website: www.fpa.org.uk
The fpa can advise on all sexual health matters, including contraception, abortion and sexual health. A range of factsheets are available to download free from the website. You can also get details of family planning clinics, sexual health clinics and other sexual health services anywhere in the UK.

websites

Bupa
www.bupa.co.uk/ ..
Information on the development of the male pill and the male contraceptive trial carried out over a 5-year period at the ANZAC Research Institute in Australia.

Male and female sterilisation
www.fpa.org.uk/guide/contracep/steril.htm
Information from fpa on sterilisation and a Q&A answering a wide range of questions on the subject.

NHS Direct Encylopedia
www.nhsdirect.nhs.uk/en.asp?TopicID=644&AreaID=4231&LinkID=3306
Information on the male pill, when it might be available and its advantages and disadvantages.

Selective Tubal Occlusion Procedure (STOP)
http://pcpoh.bham.ac.uk/publichealth/horizon/PDF_files/2002reports/essure.pdf
A new and emerging technology briefing on the STOP sterilisation procedure from the Division of Primary Care, Public and Occupational Health at Birmingham University.

reading

Future Perfect from Marie Stopes International can be downloaded as a PDF online at www.mariestopes.org.uk/pdf/future-perfect-complete.pdf or the publication can be ordered by post on 020 7574 7357.

Sterilisation for women and men: what you need to know National Evidence-Based Clinical Guidelines from the Royal College of Obstetricians and Gynaecologists.
Can be ordered as a booklet from the RGOC bookshop or is available as a download at www.rcog.org.uk/ ..

(updated January 2003, resources updated February 2005)