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A baby that is wanted and planned for, a child by choice and not by chance, that is what modern contraception offers men and women. But you have to know what's out there, how it works, and where to get it. This is really important now more than ever.

This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is the "7 Domains of Women's Health" on The Scope.

Women and men all over the world have wanted to plan their families for thousands and thousands of years, but methods used in Cleopatra's time in ancient Egypt probably weren't as effective as what is available now. If no method of contraception is used, women in sexual relationships that would make them pregnant could expect to have more than 11 babies. That's in these days of good obstetrical and pediatric care, where women are less likely to die in childbirth and babies are much less likely to die in the first five years of life. Eleven babies sound like too much? One more baby sounds like too much right now?

Let's talk about contraception. It's an egg and a sperm problem. You need to stop egg production, stop sperm production, or stop the sperm from getting to the eggs. These are the main ways that modern contraception works.

About 50% of unplanned pregnancies happen to people who are "using" contraception but using it incorrectly. This is the most common reason that methods like abstinence or periodic abstinence, think natural family planning, or methods like barrier methods like condoms or diaphragms actually fail. They weren't used correctly or at all. Methods that you have to think about at the time of sex are more likely to fail because you're more likely to fail to use them. If you combine two methods, abstain during your fertile period and use condoms all the rest of the time, your chance of getting pregnant by accident is much lower. Two methods are better than one, and this is a combo where men can be the important user. You can get condoms most anywhere, and anyone with some smarts and gumption can figure out their fertile period.

So let's talk about hormonal pills, patches, and rings. They are considered moderately effective methods or ones that have an annual failure rate between 1 in 10 to 1 in 100. That means if women use them, the chance of getting pregnant is about 1 in 10 to 1 in 100 per year. Of course, you might be at risk for pregnancy for multiple years, so these chances literally add up. Considering a lifetime of contraception using these methods, it was calculated that women would have about two unplanned pregnancies. These methods work by blocking ovulation and by changing cervical mucus so sperm cannot get to the eggs, but women don't always take the pills, or patches or rings correctly. They miss some days or they stop for a week as directed, but they stop for longer than seven days, and they are very likely to ovulate. But you could team up with your sex partner and use a moderately effective method and condoms and get much more bang for your buck birth control-wise.

Hormonal methods aren't right for everyone, and you should know by reading up or asking knowledgeable clinicians if they're right for you. Now, there may be immense hormonal contraception on the horizon, transdermal hormones to block sperm production. If it has about a 10% failure rate per year, and women taking the pill as they will, not perfectly, have a failure rate of about 10% per year, if both members of the sexually active couple use the method not perfectly, the failure rate would be about 1 in 100 per year. The two methods multiply in terms of their effectiveness. If they both used effectively, if they both, men and women used hormonal methods effectively, it would be about 1 in 10,000 women per year, and that is effective contraception.

Now for highly effective methods, these methods have failure rates of about 1 per 1,000 women per year. They are so good because you don't have to think about them and using them correctly almost always happens. These include copper IUDs, hormonal IUDs, and hormonal implants under the skin. The hormonal implants' primary method of action is to work by blocking ovulation. The IUDs' primary method of action is by blocking sperm. Copper in the copper IUD kills sperm on their way up to the egg, and the hormonal IUD blocks sperm from getting through the cervix. The IUDs and implants are highly successful at preventing pregnancy but require a trained clinician to put them in. They last a long time, the copper IUD for 12 years, the hormonal IUD for 5, and the implant for 3, but they are immediately reversible as soon as they come out.

Now, all contraceptive methods have some side effects and risks, but none have as many risks and side effects as an unwanted pregnancy. Uh-oh, did you just say, "Oops?" Did you forget to take your pills? Did the condom slip off or stay in his back pocket? Was sex forced on you and you weren't using anything? Emergency contraception is for people who had unprotected or under-protected sex. They are pills over the counter or by prescription, that must be used in the first three to five days after the unprotected sex act, and the earlier, meaning the next day or the day after, the better. The copper IUD and hormonal IUD can also be used for emergency contraception, but they aren't FDA approved for that use, and you have to find a clinician to place one in a timely manner.

Using contraception means some work on your part. You have to know what you can use and want to use. You need to know where you can get them. You need to know how you can pay for them. All this information is available from many sources, but an overall good resource is bedsider.org. Many clinics around the country provide contraception on a sliding fee scale based on the ability to pay. Most insurance plans pay for a significant amount of the cost of contraception. There's a national family planning grant called Title X, that provides low-cost contraception to anyone who needs it, and it's available in most states. But you have to lace up your boots or put on your flip-flops and do it. Children deserve to be by choice and not by chance now more than ever. Thanks for joining us on The Scope.

Dr. Jones: So you ran out of your birth control pills and the condom broke or something like that. You really don't want to get pregnant right now or anytime soon. What do we know about your options?

Many women know about emergency contraception, and many don't, something you can do to decrease your chance of pregnancy if you had unprotected or under-protected intercourse. There are two types of emergency contraceptions approved by the FDA that are available in the U.S., and they are pills, and they decrease the chance of pregnancy if they're taken within five days of unprotected intercourse. But there are other types of birth control that would work and keep on working if you're looking for contraception for more than this month.

With us today is Dr. David Turok. He is an OB/GYN specialist in family planning and chief of the division of family planning at the University of Utah. Thanks for taking some time for us, Dr. Turok.

Dr. Turok: Thank you.

Dr. Jones: What were the background reasons to ask the question of whether the levonorgestrel IUD, which is what we're going to be talking about, would work for emergency contraception? What made you do this question?

Dr. Turok: Well, I speak with people a lot about emergency contraception because I'm very interested in it, and I think it's amazing that you can use something after you've had sex to prevent pregnancy. And every time I talk about it with people during grand rounds or during educational presentations, people always, always, always ask . . . because we know we have great data to say that the copper IUD works very well for emergency contraception, people always ask, "Well, what about the hormonal IUD, the levonorgestrel IUD? Can you use that?" So 10 years ago, we started trying to gather data on this topic, and finally we have an answer.

Dr. Jones: So people came to the clinic wanting emergency contraception and they walked into the clinic thinking that they might get some pills. How did you get so many women to participate in the study when they came for just pills?

Dr. Turok: Like in many aspects of life, Utah is unique. And currently, one of the forms of emergency contraception pills is available without a prescription. You can just walk into pharmacy or supermarket and get them. Sometimes it's behind the counter, you might have to ask, but you can get it without a prescription.

In Utah, because there are many limitations for people, young people especially, with insurance coverage, people seek out the cheapest place to get it, and that is Planned Parenthood where there's a sliding scale and where people have known for a long time that they can get the pills.

And we've done a few different surveys and a few different kinds of projects where we offer people walking in for emergency contraception IUDs, and it's around 12ish percent of people are interested in an IUD in that setting. And that's, I think, potentially driven in Utah by the fact that people don't have adequate insurance coverage and they're looking for opportunities to get better methods of contraception. And when there are low or no-cost options presented, people are interested.

So, at the peak before Plan B, one of the pills was available over the counter. Planned Parenthood statewide distributed more than 50,000 doses of oral emergency contraception. So people know, and lots of people come to Planned Parenthood clinics in our state for the service, and when you present them with IUDs, some are interested in it.

Dr. Jones: So some of them are really looking for something for longer than just this month?

Dr. Turok: Exactly. Yes.

Dr. Jones: Right. So you've known that the copper IUD . . . we've all known from data that goes back 20 years, really, that the copper IUD works. So you then offered them either a copper IUD or a hormone-containing IUD. And what did you discover?

Dr. Turok: So what we found in this study where we randomized people to get one or the other type of IUD, either copper or the hormonal IUD, we found that the pregnancy rate was low, very low, in both groups in the month after.

So with copper IUDs, we had 321 people who were assigned to that, and we got one-month outcome data on. And we expected in that group, zero or one would have a pregnancy. And it was zero.

And with the levonorgestrel group, we really didn't know. We had built into the study stopping points. Like, if there were a bunch of pregnancies early on, we were just going to stop. But what happened was there were 317 people who got the levonorgestrel IUD and there was one pregnancy. Lower than we thought and much better than the pills.

Dr. Jones: Right. That's important because the methods that are currently FDA-approved, that those 50,000 women who came to our clinics seeking pills, the failure rate or the ineffectiveness rate is much higher than what you found with the IUDs, either one of them.

Dr. Turok: Yeah. To me, one of the very cool things about the study is the other studies that got FDA approval for those oral methods, these were things that took a long time and hundreds of millions of dollars were spent to go through the FDA process to get that approval. And in this study, we took a method that was already FDA-approved and we just showed that it works for this as well.

And the upside relative to the pills is, as you know, that people who are getting this can get . . . this is not just better than the pills for this one event, but you can continue to use it as long as you want, up to seven years, or for the copper IUD, up to 12 years. And that is a set-it-and-forget-it method.

Then for the LNG IUD, there's this side benefit, which is why it's more popular than, I think, the copper IUD, in that it dramatically reduces or eliminates both menstrual bleeding and cramping. And that is a big upside. And that's why I think people really wanted an answer to this.

Dr. Jones: Well, we have some evidence from another big study that just gave women what they wanted when they asked for contraception and then followed them, that the IUDs were something like 20 times more effective than birth control pills in preventing pregnancy?

Dr. Turok: Correct.

Dr. Jones: So if a woman comes to our clinic for an emergency contraception and she wants long-term reliable contraception, would she be offered an IUD, do you think, in our clinics? Because now that the work was done around here, I'm hoping that our clinicians know that it's an option. Do you think it's going to be used in the clinics?

Dr. Turok: I want to say absolutely.

Dr. Jones: I do, too.

Dr. Turok: But I would also say as our team is working on getting this paper published, I would occasionally have these pangs of terrible thoughts that 10 years down the road, it's going to be like the authors of this paper and 10 other people that we know that know about this and nobody is going to ever have done any of it.

And so I started making lots of phone calls and sending lots of emails to people who I thought would be critical partners in disseminating the information. And one of the things that helps get the word out a lot is getting the paper published in a high-impact journal.

Dr. Jones: Right. It was published in "The New England Journal of Medicine," which is probably our premier medical research journal, I think, in the United States, or one of them.

Dr. Turok: One of the, I think, nice things about the study is "The New England Journal" publishes papers that change practice. That is their main motivator for selecting research articles. And you have a very low chance of submitting something and getting it published. But it was very reassuring to know that they felt this was important enough to be published there and that they were confident that it would change practice.

And there are lots of other organizations, professional organizations, a variety of health practitioners, and providers that can disseminate this to people who work with them.

I also have been working with the people from UpToDate to revise the article on emergency contraception to incorporate this and they were amazing. ACOG carried a piece on their listserv email and we're going to work with them to try to update Lark information in their emergency contraception information. So there are all kinds of ways to get the information out.

And a really important place to do that is also with Planned Parenthood Federation of America. As you know, they have something called the National Medical Committee that makes decisions on changes in practice. So I just sent an email and lately before this interview responding to questions from people who organize the National Medical Committee about this.

It's, I think, a great opportunity for Planned Parenthood Federation of America to lead on the dissemination of this because the information came exclusively from Planned Parenthood clinics. This is a collaboration between our team at the University of Utah and Planned Parenthood Association of Utah.

If you look at what gets published in "The New England Journal," the vast majority . . . and currently, probably nobody is a more fastidious reader and consumer of their publication than you. If you look at those trials that get published, most of them are these big, multi-site, and sometimes multinational studies with tons of sites and huge numbers of participants. This study is different.

Dr. Jones: It is. It's really amazing that you have a very local group who was completely committed to answering the question. And I think that that's a phenomenal thing.

I think, at The Scope, we're trying to get the word out also to individual women so they might be willing to come in and ask. So not only do clinicians need to know, but if individual women say, "By the way, do you think I could get this IUD today? Do I have to wait?" that changes practice.

Dr. Turok: Absolutely. So the education and dissemination of information have to be from push and pull factors from supply and demand side. And as I had mentioned, we're already working on trying to get providers up to speed. But there's lots of opportunity that we're going to be working on to make sure that people who are seeking emergency contraception will know about this.

Obviously, the internet is a fabulous place to do that. And there are also some organizations that focus specifically on emergency contraception. There's a U.S. Emergency Contraception Consortium and an International Consortium of Emergency Contraception, and they are fabulous at providing consumers information about different products and ways to access them. So we look forward to working with them as well.

Dr. Jones: Right. Well, Dr. Turok, I am very grateful for your time, and we'll work at The Scope in trying to get people the information they need. But the research to answer this kind of question takes years and takes a team of dozens of nurses, and clinic staff, and researchers, and above all, it takes hundreds of women who are willing to participate, answer questions, and follow up. To all of them, we are very grateful because "I hope I just didn't get pregnant" isn't a very good birth control method. And it's been a long time coming and I'm so glad to see it here. Thanks a lot, and thanks for joining us on The Scope.

Dr. Jones: I was talking to a group of 11 college students, all women, about family planning. They said, "We aren't really interested in family planning because we aren't planning any children right now." Really? What am I not getting here?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Sometimes you think people you are talking to know what you mean. Well, that's a mistake for sure. I make assumptions that young people in college know how their bodies work and about contraception, but maybe I'm wrong.

Today in The Scope studio we're talking to Grace Mason, a college student who knows a lot about contraception and is learning a lot about what her fellow students know and don't know. She is the founder and President of the Campus Contraceptive Initiative here at the University of Utah. Welcome, Grace.

Grace: Thanks for having me.

Dr. Jones: So, Grace, by the time young people get to college with all that's out there on the internet, they're pretty well-informed about contraception. Right?

Grace: Well, you would hope so, but unfortunately since less than half of the United States mandates contraceptive education and sexual education broadly, a lot of students come into college without having any sex ed. And a lot of students don't experience medically accurate sex ed in that regard. So if they come out, they may come out of high school with misinformation.

And so when we hope that students will turn to the internet to get better information, there's also a lot of misinformation on the internet that they're quite easy to find as many different people will tell teenagers what they should believe about sex ed rather than what their bodies do and how their bodies function.

So I think that students frequently come in believing things or not knowing anything and hoping that anyone will tell them the truth about how their bodies work.

Dr. Jones: Well, there's a lot of sex in the media, and there are books and there are songs, but none of them actually represent sexual initiation or contraception at all. No one says, "Oh, yeah, what are you using for contraception?" They never had that on the TV. So I read that one of the main reasons that men and women don't finish community college in the way they planned was an unplanned pregnancy. How can we change that?

I mean, if people are coming to college, they planned their college. But now they have to stop or have an interrupted course because of a baby that they didn't plan. What are we going to do about that?

Grace: I think that it is a broad issue, and it's something that Healthy People 2020, it's a huge part of their initiative is reducing the unintended pregnancy rate and increasing the intended pregnancy rate, because at the moment, 45% of pregnancies are unintended. And for students in college, who are 18 to 25, they are the most likely to experience an unintended pregnancy and they're also the most likely to be uninsured.

So there's a variety of issues there when it comes to a lack of knowledge and education coming into college. There's a coverage gap. There is the expense of care, which tends to be about $600 or more out of pocket for uninsured students.

Dr. Jones: For contraception?

Grace: For contraception.

Dr. Jones: If they want a long-acting method. It's cheaper if you're using condoms, of course.

Grace: Of course, but condoms are less reliable, and a lot of students don't like condoms in the sense of like their pleasure. And as they are less reliable, students are hoping to find a method that works with them.

Dr. Jones: So tell me about the Campus Contraceptive Initiative.

Grace: So the Campus Contraceptive Initiative is a interdisciplinary group of students, researchers and providers who are all targeting that issue of college completion, graduation and promoting family planning.

And so we are working through research and education to expand access to services, because we find that a lot of students don't know about the different options that they have when it comes to contraception. And so when it comes to finding the best method, they first need to have the education and that step of these are all the methods available to you. And then what does it look like in pricing? What does that look like for coverage? Where can you actually get those services?

Dr. Jones: So you've been doing a survey. You did a little survey last year, and you've been working on one this year. Any clues from your science so far in terms of what are people thinking out there?

Grace: Yes. We have definitely found out a lot of interesting things. That first survey, that went out last February, we got about 330 students to respond, and they were asked questions about their current sexual health, their knowledge as well as their desire or interest in a low-cost contraceptive clinic on campus.

We found out that 1% of students are currently going to the Student Health Center on campus, and that really blew us away because we found out that a lot of students are going to their doctor, but we know that a lot of students aren't comfortable with telling their parents about the services that they get.

And so that we have this huge uninsured gap of students where if they were able to access care at the Student Health Center, maybe they're being turned away because of the out-of-pocket prices, maybe they're being turned away of not knowing their options.

Dr. Jones: The Student Health Center, it may be student health, but it still has to be paid for. So students, unless they have that particular kind of student health insurance, still have to come up with money, and maybe their parents, if they use their parents' insurance, then their parents are going to get the bills or get the copays or get the information at home, so privacy becomes an issue.

Grace: It definitely does. And we saw that students, when asked about if they could have low-cost, affordable methods, 95% of students said, "Yes, I am interested in that." And many of those students said that they would actually partake in a service like that.

But broadly students want to know about the methods. We found that it wasn't just the birth control pill that was popular. If we were to have this contraceptive clinic, it was options. Across the board students want options for their birth control.

Dr. Jones: So where can college students get information about contraception? What methods are out there? How they work and where and how to get them? What's good information? What could they do right now?

Grace: Well, I would say that there are two wonderful resources out there. Bedsider.org is one. They have an incredible comprehensive list of different options, how they work, the different varieties. For example, since the IUD, there are several different types of IUDs, being able to click on each one and seeing how they're different and what they might do.

And they are wonderful because they also can connect you with emergency contraception to your door or sending your monthly birth control to your door rather than going in clinic. And so they have a great set of resources. Also Planned Parenthood Learn, which is an offshoot of the broader Planned Parenthood website, also has a really user-friendly interface that can compare methods and look at methods and connect you to one of their clinics.

Dr. Jones: Okay. So both of these options have a place where you could put in your ZIP code and you can find out clinics where you could get healthcare?

Grace: Yes.

Dr. Jones: Well, that's good to know, and people need to know more. And having a reproductive life plan, a family planning plan is important if you want to have the family that you want when you want it, or if you don't want it, get the knowledge that you need and get it right. You worked hard to get into a university and you're working hard to finish, and this part of your life takes a little effort, but it's worth it. And thanks for joining us on The Scope. And thanks, Grace.

Grace: Thank you.

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Are you happy with your family size? Have you had all the kids that you planned or a few more? Are you considering having your tubes tied? Let's talk about that.

Prior to the development of effective hormonal contraception, women choosing to end their childbearing through sterilization procedures had major operations to remove their fallopian tubes or had hysterectomies. Although the history of female sterilization is clouded with cases where women may not have given informed consent, since 1960, about the same time that birth control pills came on the market, techniques for female sterilization became less invasive and easier to do with less risk. The term used for these easier techniques is tubal ligation.

Now, there are many techniques and the timing for this procedure, and about 30% of American women have had a tubal ligation. Techniques include taking a suture and tying it around a loop of tube and then cutting the tied-off loop of the tube out. And then there are a number of techniques like this to remove the middle segment of the fallopian tube so sperm cannot get to eggs and fertilize them. Other techniques include putting a clip to close the tube permanently, or cauterize or burning the tube in the middle to close it.

The timing could be shortly after a baby is born, within a day or so, while the woman is still in the hospital, or at the time of Caesarian section when the tube is right there, or anytime between children, when the procedure can be done by laparoscopy. But half of tubal sterilizations occur right after the baby is delivered vaginally or by Caesarian, and that comes to about 350,000 tubal sterilizations a year.

The word "ligation" in the term "tubal ligation" means to tie. This unfortunate term translates into tying your tubes. This has led some women to assume if you had your tubes tied, it would be simple to untie your tubes, like untying your shoelaces. Tubal ligation can be reversed surgically for women who regret having had a tubal sterilization, but it's expensive and it doesn't always work.

For years, it has been noted that tubal sterilization decreased the risk of some types of ovarian cancer by 30% to 50%. Now, that's significant. Now, we're getting to the main topic of this little podcast. The lifetime risk of ovarian cancer in the U.S. is about 1.3 out of 100 women. Ovarian cancer is particularly deadly because it spreads early, and we don't have any early detection methods the way we do with breast cancer, like a mammogram, or cervical cancer with a Pap smear. Ovarian cancer comes in different types, but one of the most common types, serous ovarian cancer, may often actually arise in the end of the fallopian tube near the ovary. For this reason, women who have genetically-linked risks of ovarian cancer, such as the BRCA1 and 2 mutations with familial breast and ovarian cancer, are recommended to have their ovaries and their fallopian tubes removed when they finished having their families.

Recent studies have suggested that women who are planning a tubal sterilization who have their tubes completely removed have about a 60% reduction in the risk of these serous ovarian cancers compared to women who didn't have a tubal sterilization or women who just had part of their tubes removed at tubal ligation.

Now, there are other advantages to having the entire tube removed if a woman is planning a tubal sterilization. Tubal ligations have a known failure rate, a pregnancy after the procedure of as much as 3 to 5 pregnancies per 100 women over 10 years who had their tubal sterilization at the time other than when the baby was delivered, with laparoscopy. Women who had their tubes completely removed have a much lower failure rate, almost zero. Women who have a tubal ligation also have an increased risk of ectopic pregnancy or tubal pregnancy if they do become pregnant compared to women who've had their tubes removed completely.

Now, we know that putting a little clip on the tube, burning the tube, or cutting a loop of tube is quite simple and takes a very short time. Anybody could do it. Removing the whole tube takes a little longer. Studies recently published looked at women who were randomized to removing the whole tube at the time of tubal sterilization or cutting a loop out at the time of Caesarian section an easy time to do it as the tube is right there to look at and operate on.

One study used an advanced technique to take out the tube completely and found that time was only about five minutes longer compared to the standard procedure of taking out just a part of the tube. Another study using older techniques suggested took about 10 to 15 minutes longer. There was not significantly more blood loss with taking the whole tube out compared to just part of the tube.

The other issue is that if the entire tube is removed, you cannot come back and have your tubes untied or put back together again the way you might if only a part of the tube is removed. Of course, these days, many women who choose to have more children after tubal sterilization will use in vitro fertilization and it doesn't matter if you have part of a tube or no tube. Although IVF is expensive, so is surgically putting the tube back together again. And in some cases, IVF may be more successful.

So if you're planning a tubal sterilization, your tubes, not your husband's tubes, that would be a vasectomy, consider the following. If you have a BRCA1 or 2 mutation or have a strong family history of ovarian cancer, you should have your entire tubes removed when you have your tubal sterilization, whether it's right after the baby is delivered or sometime later. And often, women also had their ovaries removed.

If you have concerns about ovarian cancer, and you're planning a tubal sterilization, talk with your OB-GYN about taking the whole tube out. If you don't have a family history of ovarian cancer and the concern of the risk of ovarian cancer isn't high on your worry list, think about the benefits and risks that were just mentioned and discuss your options with your OB-GYN. Many OB-GYNs are discussing tubal removal as an alternative to tubal ligation when women are planning a tubal sterilization. Whatever you choose, we're glad you are informed about new options and old options in planning your family, and thanks for joining us on The Scope.

updated: September 10, 2020
originally published: August 9, 2018

Dr. Jones: Uh-oh, now you have a family planning emergency. How much time do you have? This is Dr. Kirtly Jones from obstetrics and gynecology at the University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Today in The Scope studio, we're talking with family planning expert in emergency contraception. And what are the options and how do they work? Dr. Jennifer Kaiser is an OB/GYN at University of Utah Health and is currently in the family planning fellowship here. Welcome, and thanks for joining us and helping us out with this emergency on The Scope, Dr. Kaiser.

Dr. Kaiser: Thank you so much.

Dr. Jones: Well, when I was a young woman in the last century, we thought that a douche with Coca-Cola would work for emergency contraception. And douching with various chemicals after intercourse has been used for hundreds of years. Any truth to this ancient medical practice?

Dr. Kaiser: So there might be. I actually think one fascinating aspect of contraceptive care, both prophylactic, so using before intercourse or emergency using after, is how women have attempted to control their fertility for so long, for like you said . . .

Dr. Jones: Of thousands of years.

Dr. Kaiser: Of thousands of years. And in our modern era, though, we have plenty of options for birth control. And on the whole, women have really heard about all of these different options. In the past, this wasn't the case. Prior to the creation of the birth control pill in the 1960s, there really weren't any tried and true methods that were widely known. Women and their partners tried using home remedies that were passed on by word of mouth or methods they had read about in magazines. And douching, like you mentioned, was actually extremely popular as a means of preventing pregnancy following intercourse.

So in the 1800s, women could actually purchase special made syringes to douche with. They would use a wide variety of liquids for this, anywhere from cold water to tepid water, to hot water, boric acid, baking soda, and all sorts of astringents. And so we all know how acidic Coca-Cola is as we've seen people's YouTube videos of it dissolving all sorts of things. And it seems that douching with an acidic or basic compound is probably more effective than just water. So there is likely some truth to this, douching with either Coca-Cola or an astringent kind of liquid.

Sperm are very temperamental, and so they don't do well in a pH that's outside of the seven to eight range. So it may be very likely that the sperm were being killed with these kinds of treatments in the vagina or even the lower cervix. But that doesn't really cover the uterus or the fallopian tube where the sperm can get to in as little as 15 minutes. So if you're not right on top of it, it's really unlikely to work.

Dr. Jones: Oh, well, but let's move on to something that we know works a little bit better. So why do they call it emergency contraception? Why do we use that word?

Dr. Kaiser: Yeah. So in general, emergency contraception is so called because it describes the use of a contraceptive method in an emergent setting to prevent pregnancy. So that can be after unprotected intercourse, a rape, or after method failure. So somebody who was using a condom that broke or maybe they had some pills that they missed. This term has also dramatically changed over the past several centuries. In the 1800s, most contraceptive methods practiced were after intercourse with the notable exception of withdrawal or condoms. And so really, in the past, everything was emergency contraception.

The term post-coital contraception was used by scientists and physicians in the 1960s once the pill was created. And the popular media coined the term the "morning after pill" shortly after, which I'm sure is a familiar term to many listeners. But since the 1990s, the term emergency contraception was adopted to really emphasize that this shouldn't be an ongoing birth control method.

Dr. Jones: Right.

Dr. Kaiser: That it's for emergency use and then it also was used to correct misconceptions about when to take emergency contraception, the fact that it's not just limited to the morning after.

Dr. Jones: Right. But it is kind of urgent, and it's not likely to be available in an emergency room unless you're seeking health care in the ER. That's not the place you go for this unless you're already going there for, perhaps a rape or something violent, unfortunately, right? So what's available?

Dr. Kaiser: Yeah. So right now on the market, there are three current available forms of emergency contraception. There is Plan B, which is a synthetic progestin called levonorgestrel.

Dr. Jones: And it comes in other names too. There are a couple brands of this, yeah.

Dr. Kaiser: There's also Ella which is ulipristal, which is another progestin acting medication. And then there's also the copper IUD or para guard.

Dr. Jones: Okay. So let's pick Plan B or drugs like that. How does it work, and when is it too late for Plan B to work?

Dr. Kaiser: Yeah, those are great questions. So Plan B is an oral synthetic progestin called levonorgestrel. By taking this pill, the progestin in it blocks your body's ability to produce a surge of the hormone called LH or lutenizing hormone. By blocking the surge, ovulation is prevented so no egg is released, and thus fertilization and pregnancy are also prevented.

If it has been more than 72 hours from unprotected intercourse, there is less of a chance that Plan B will work. So in other words, it's best to take it within 72 hours, but it can be taken up to 120 hours from unprotected intercourse. But if you've already ovulated before taking Plan B, it's not going to work to prevent pregnancy.

Dr. Jones: Right. Okay. Well, can anybody take Plan B?

Dr. Kaiser: So the great news is that Plan B is now available over the counter at many pharmacies. There is no age limit as far as who can take or purchase Plan B over the counter at these pharmacies. And really, there's no reason why a woman can't take Plan B. The thought is that it's that there are no medical conditions that outweigh the benefits of taking and using emergency contraception.

Dr. Jones: Right.

Dr. Kaiser: The only aside to that is that there may be a little less efficacy if you weigh over 165 pounds.

Dr. Jones: Okay. Well, then let's talk about ulipristal or Ella.

Dr. Kaiser: Yeah. So ulipristal or Ella, also very similar to plan B in that this pill also interferes with the LH surge and prevents ovulation. But it also does this in a slightly different manner. So ulipristal actually blocks the progesterone receptor in the body which is associated with the LH surge and ovulation. So it mainly works through blocking the LH surge, but it may also postpone the release of the egg from the ovary.

So even if your body has already undergone the LH surge, it might be that Ella helps prevent the egg from being released from the ovary. And because of this and how it works in your body, Ella is actually effective for up to 120 hours from unprotected intercourse. The only downside to this one is that you need a prescription from a physician.

Dr. Jones: Now, neither of these, you know, once you take it, it isn't protecting you for days and days after. So you can say, "Well, I've taken it now and maybe it'll help me out. I just will have unprotected sex for the next week." It really doesn't work that way. In fact, that's often why people think it fails is because they kept having unprotected sex.

Dr. Kaiser: Exactly. So you know, like I mentioned, if you have taken it within the 72 hours for Plan B or the 120 hours for Ella, and your body has not ovulated yet, you are going to be protected from that one episode of unprotected sex. If you continue to have unprotected sex, like you said, Dr. Jones, for the remainder of the week, it's not going to work, you're going to need birth control for that.

Dr. Jones: Yeah. Because eventually you're probably going to ovulate, right?

Dr. Kaiser: Correct.

Dr. Jones: Okay. Well, what about the copper IUD? How does that work? And when is it too late?

Dr. Kaiser: Yeah. The copper IUD is actually a really exciting recent development in emergency contraception. So it combines the best of both worlds, like we're just talking about Plan B and Ella aren't going to protect you going forward. It's just for that one episode of unprotected intercourse. The great thing about the copper IUD is that it can give you really effective emergency contraception, and it gives women a long acting, highly effective method of birth control going forward. So this kind of method, once you get it, you can keep having all the unprotected intercourse that you want.

Dr. Jones: But it won't be unprotected anymore.

Dr. Kaiser: Right. Exactly, exactly. Now you have a great method. So we don't actually really know entirely how this works so well as emergency contraception, but we suspect it has to do with creating an inhospitable environment for sperm to prevent fertilization. But copper IUD may also impair implantation of a fertilized egg in the uterus. But again, we're not really entirely sure just how it works.

The great thing about the copper IUD as well is that it can be used for up to seven days following unprotected intercourse. So if a woman finds herself in need of emergency contraception and isn't interested in a pregnancy in the near future, the copper IUD is really a fantastic option.

Dr. Jones: Right. But it's not something you can get over the counter, and it's not something you can use yourself.

Dr. Kaiser: Correct.

Dr. Jones: You need to see someone who's good at putting in copper IUDs.

Dr. Kaiser: Right. So you would need to see a physician who would be able to place this IUD.

Dr. Jones: Or a nurse practitioner.

Dr. Kaiser: Or a nurse practitioner or a PA, whoever is available that has training, who can place one for you.

Dr. Jones: Right. Well, we don't want any woman to have a family planning emergency. We want everyone who isn't planning a pregnancy protected before they have sex. But you know, if stuff happens and now there are some options and some you can get online, check out our Scope podcast on emergency contraception over the internet. And thanks, Dr. Kaiser, for joining us. And thanks, everyone, for joining us on The Scope.

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Dr. Jones: Oops, you now have a contraceptive emergency, but your doctor's clinic is two hours away and you don't have the car. The closest pharmacy is an hour away, but the pharmacist is your father-in-law. So what are your options? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.

Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.

Dr. Jones: Okay, the condom broke or you didn't use protection. What are your options?

Number one, you can cross your fingers and hope you don't get pregnant. If you and your partner are young and healthy, and the "oops" came around your fertile period, and isn't that usually just the case, the chance of getting pregnant is between one and three, and one in four.

Two, you can use emergency contraception. Emergency contraception comes in three types, and they're all quite different. One is a progesterone hormone common in birth control pills that's taken in a higher dose in a pill within 72 hours of unprotected intercourse. One brand name is Plan B, and the others are Take Action and Next Choice One-Dose. These are available over the counter in many pharmacies, but not all, and should be taken as soon as possible, as it won't work after you ovulate and become pregnant.

Another pill, called Ella, is available by prescription, and it works for up to five days by blocking ovulation.

And lastly, a copper IUD can be placed, and it's the most effective, but it requires that you see a clinician who can place it and place it right away. And depending on your insurance, it can be hundreds of dollars, but it offers highly effective contraception that's immediately reversible for up to 12 years.

If you want to get emergency contraceptive pills, you can get them online and delivered to your home. This is not cheap, and you need a credit card, but several websites are available to women around the country, and FedEx delivers almost everywhere. You can Google "emergency contraception online," but be careful as you need a credible and reliable source.

The Princeton University website on emergency contraception is good, and the website, bedsider.org, will take you step-by-step. Both of these can direct you to the best places to order emergency contraception online. Both of these will also give you more in-depth information about emergency contraception.

Ella, the pill that works for up to five days, might be the best choice. Plan B needs to be taken sooner and isn't as effective for women over 165 pounds. You need to go to the websites recommended by the Princeton emergency contraception website or bedsider.org and set up an account.

You need to fill out a questionnaire that might take 10 to 15 minutes, and then fill out shipping and billing information. You need a credit card, and the current price for online consultation, the medication, and the overnight shipping, but probably not on Saturday or the weekend, is $67. It comes in a little box wrapped up in a bigger box, and you have to be present to accept it at your home.

If you want them to send the prescription to a local pharmacy, the one where your father-in-law doesn't work maybe, you can give them the number and it's a little cheaper, but you have to pick it up pretty soon. Don't wait a week.

Many women who would choose emergency contraception have limited access. They don't have a doctor. They don't live near a health clinic that will take drop-ins. Emergency rooms don't consider this an emergency, and it's very expensive to use an emergency room for emergency contraception.

Women might prefer privacy and confidentiality, which they might not have in their local small-town clinic or pharmacy, where everyone knows everyone. Getting emergency contraception online is an option, but it isn't cheap. You need to have a home address to receive the delivery, and you need a credit card.

Of course, we all hope that you and your partner are well-covered with contraceptive methods that are effective and that you don't have to think very much about so you won't even need emergency contraception. But if you need emergency contraception, there are some options, much better than crossing your fingers.

Thanks for joining us on The Scope.

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Dr. Jones: What would the life of women and their children look like if every woman had the information and ability to plan every pregnancy? This is Dr. Kirtly Jones from obstetrics and gynecology at University of Utah health care, and this is The Scope.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: In the United States, almost half of all pregnancies are unplanned. In about half of those, the unplanned pregnancies were mistimed and about one-half of those pregnancies were unwanted. What would happen in the lives of women if they had all the information they needed to make a careful decision about pregnancy, or contraception, and they could get any method of contraception they wanted for free? Dr. Turok is a clinical professor in the Department of Obstetrics and Gynecology here at the University of Utah and a specialist of family planning.

Welcome, Dr. Turok. What happens in young women's lives when they have an unplanned pregnancy?

Dr. Turok: The largest group of women who have abortions in this country are those who have unintended pregnancies and as you mentioned, it a lot of people. It's over a million women a year. And for women who continue with a pregnancy, pregnancy is a chaotic time, as is child rearing, and if you're not planning for it from the get go, it further complicates things.

A population of people who have had planned pregnancies and a population of people who have had unplanned pregnancies and the children thereof, the kids from unplanned pregnancies are more likely to be born premature, to end up in the newborn ICU, to have less medical care in their first year of life, to do less well in school, and to not finish school.

Dr. Jones: So there are good reasons to build a structure around which families can be planned. We all want the kids that come to us, we don't all, but most of us want the kids that came to us because we, after the fact, create this incredible story about our kid was the miracle we didn't planned, but we love. But there are consequences to having babies that aren't planned.

Dr. Turok: There certainly are. The best predictor of having loving parents around to care for a child is to have been planning for that child from the beginning. And it's such an important predictor of how well children do that anything that we can do to help people time their pregnancies so they end up with the children they want, when they want them, only helps everybody.

Dr. Jones: In other countries, I know Europe does a pretty does a good job, people in Scandinavia do a pretty good job planning their children. What's keeping us in the U.S. from planning our children? Why do we have the highest rate of unplanned pregnancies in the Western world?

Dr. Turok: The difference between Scandinavia and the United States are many things. It's sexuality education, it's the conversations that children and young people and their parents have regarding the expectations for intimate partners. And it's the availability of contraception. In Scandinavia many more women use the most effective, reversible methods of contraception like IUD's and implants. And what we've seen in the United States in the past decade is that as communities and states have broadened the availability of these most effective methods, the rates of unintended pregnancy and abortion have plummeted.

Dr. Jones: What is it about America? Is it that we are a multicultural country? Because we don't have a unified healthcare system? Is it because we have diversity in income across the country? We have people who are truly poor. Why are we different than the Scandinavians, other than we don't have as many blonde people?

Dr. Turok: The biggest thing we see in disparities of unintended pregnancy are along socioeconomic lines, and race and class, and women of color, women who have completed less education, women who have fewer financial resources, are much more likely to have unintended pregnancies. In making opposites available and really removing all barriers to obtain methods of contraception will aid those people in determining when and if they have children.

Dr. Jones: We still have to reach out though to women. Women have to be thinking about contraception rather than just saying "oops", or, This is just what happens to me, and it happened to my mother and it happened to my sister." So how are we going to reach out to a vulnerable population of women here in Utah, here in Salt Lake County, to get their attention and say, "Are you sexually active?" Or whatever that means. "Do you want contraception? Do you want it for free? Come and see us." How are we going to reach out to the people who don't think they're going to get pregnant?

Dr. Turok: We've been working on this for quite some time, and the number one place people who want to initiate contraception, who have barrier of obtaining it come to in Salt Lake County is Planned Parenthood. So that's why we are collaborating with the four Planned Parenthood clinics in Salt Lake County to provide any method of contraception that women want that's offered at those clinics for free. And that includes the most expensive and the most effective methods, which are IUD's and implants.

Dr. Jones: And women who come in, they can get their method for free, but some of them actually might be willing to let us contact them in the years to come to see what happened with their lives using whatever method they chose.

Dr. Turok: Right. So we've started this project called "HER Salt Lake," or the HER Salt Lake Contraceptive Initiative, and what it does is we have three six-month periods. The first period is just the way it has been for very long, where people essentially have to figure out how they're going to get their method and pay for it.

The second period we eliminate all the costs. You walk in, you get the method you want, regardless of the ability to pay. And you don't pay anything.

And the third six-month period, we have a media campaign where women 18-29 years old will receive information on they had held devices that promotes the information about IUD's and implants and connects them with the places where they can get it for free. It'll be on Facebook, it'll be on Twitter, but it'll also be on pop up ads. It'll be modulated along the way to optimize the message and the way people receive it and when they get it. It requires a lot of community support, and support from outside resources, but we can get this done and we're working on creating a durable solution for this.

Dr. Jones: Years ago we had a picture of a pie which looked at the pregnancy outcomes in this country with the unplanned rate at a little over 50%, and for years and years that didn't budge, and you told me that your life's work was going to be to move the needle. How do you think it's going?

Dr. Turok: Yeah I think what I said was, if the shape of the pie doesn't change during the course of my work life, I'm going to be really upset that I didn't spend enough time skiing with my kids.

Dr. Jones: Dr. Turok, thanks for joining us and thank you for moving the slice of the pie that will be afforded to children who've been planned.

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Dr. Jones: Why can't a woman be more like a man? In the musical "My Fair Lady," Professor Higgins for singing his frustrations in his research project to turn Eliza into a proper lady. But in healthcare the, difference is important. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope

Dr. Jones: Men and women aren't the same. However, in the history of research into health outcomes in medicine, men's biology was the default mode. Except in Obstetrics and gynecology, of course. Researchers were wary of including women in the studies because they knew that there could be variations in how the body worked and how drugs were metabolized during the menstrual cycle. And men, of course, were the same every day, which was not quite true.

Also, women might become pregnant and for untested drugs undergoing research into dosing and side effects, that would be a problem until drug safety was established. So we counted on men to go into the risky drug development battlegrounds, but not anymore. Gender health medicine has become a significant focus at the National Institutes of Health. Research funding requires that a woman be included where appropriate. For instance, not necessary on prostate research but very important in diabetes research. Okay. Well, what are some of the differences?

Body size. Of course, we know that men are often bigger than women, but not always. If body size alone were a bigger factor, we should be dosing drugs by body mass index, or body surface area or just weight. But body size does predict lung size, heart size, artery size and kidney size and the size of the organs may predict how it metabolizes drugs or how it's affected by disease. For instance, a woman's heart vessels are smaller and they might clog up a little more easily and more quietly. Women are less likely to have a massive heart attack and more likely to quietly have heart damage leading to heart failure.

What about body composition? Women carry more fat than men, usually. This may affect how some drugs are stored. Some drugs are distributed in water and some are bound by fat. This can be somewhat important in anesthetic agents, which are fat soluble and might be taken up by fat in women leading to a lower effect per weight in women.

Anatomic shape. Well, we know girls are curvy, but some girls are more curvy than others. Most women have a different hip configuration than men. They have wider hips and that is hip bones, not just fat on the hips. This means that the angle from the hip to the knee is bigger and men's legs are straighter from the knee to the hip. Now, this is important in the rate of knee injuries in female athletes, which is greater than men. And a knee replacement in women doesn't have to be smaller, it has to have a different angle. This is important for your orthopedic surgeon to know.

Absorption. We absorb pills through our stomach in our intestines. Women have slightly less stomach acid and slightly lower gut transit time, which can make some drugs stay around longer to be absorbed more. Of course, there are some men who have lower stomach acid and lower transit times as well.

Metabolism. Women make more of certain kinds of metabolic enzymes in the liver, particularly women on oral hormonal contraception or women who are pregnant. This is particularly important in certain anti-seizure drugs, which may be less effective in women and doses may need to be changed. On the other hand, women have smaller kidneys and less kidney function as they age. So drugs metabolized by the kidneys can hang around much longer in older women.

Another important difference is in narcotics, for which women have a greater effect at lower doses. The same thing with alcohol, women have a greater effect at lower doses. The same is true for some prescription sleeping pills, for which the FTAs implemented labeling to make sure that doctors and patients know that women should be prescribed lower doses.

Now there is the "we don't know why" core category, one of my favorite categories. In this category, we don't really know why there is a difference. We don't know why women have less serotonin than men in their brains. So anti-depressants and anti-anxiety drugs like selective serotonin reuptake inhibitors, SSRIs, have a greater effect, are more effective in depressed women than in depressed men.

All these differences can lead to different side effects in women compared to men. Women have more side effects in drug studies than men. They have more nausea as a side effect. So what should we do about this as clinicians and as patients? First, we should be wary of assuming that all men are alike and all women are alike. We've already been in trouble to say all people are the same, they're all like men. But not all women are the same and not all men are the same. The differences between men and women are evident when we look at large groups of each sex, but individuals may be larger, smaller more or less fat, have different metabolisms than average for their sex.

If our medicine isn't working in the way we hoped, we should take a look at the individual and ask if different dosing or a different drug should be better. If you're having a side effect from a drug, you should let your clinician know. If you're being prescribed a drug or a course of the action like physiotherapy or joint replacement, you should ask your clinician if there are differences between men and women and how should their recommendations be modified.

I read a research study from Japan where there words like "obese" or "fat" or "overweight" were flashed in front of the eyes of men and women in functional FMRI. In men, the brain activity went right to the language center of the brain. "What was that word?" In women, the brain activity went all over to the language center, to the emotion center, to the judgment center. I hope they didn't spend too much money on that study because every woman and man I know could have told them that women are different than men.

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Dr. Jones: You just had your first baby. I mean JUST and the doctors ask you what you want to use for contraception. You blink, go blank, and say, "I'll think about that later." But the best time to think about planning your next baby might be right now. This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at the University of Utah Health Care, and this is postpartum contraception on The Scope.

Announcer: Covering all aspects of women's health, this is The 7 Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: Traditionally women and doctors have talked about planning for the next baby and spacing your children at the six week postpartum visit. And that's good, but a very high percent of women have already had sex before their first postpartum visit, and a very high percent of women don't even go to their postpartum visit.

Life and the new baby get in the way but there is a very good evidence that it's a very good idea to space your children at least two to three years apart. So what's the evidence? First, there's the case for the mom. Mom needs to have their uterus to heal, especially if they've had a caesarean and about one out of five women American women are going to have a caesarean, and in some places, one in three. And babies born sooner than 18 months from the last pregnancy are more likely to be smaller and more likely to be premature.

And women, hopefully, can breastfeed for 6 to 12 months, which is pretty good contraception, and another pregnancy can get in the way of breastfeeding. So women who've had a caesarian and get pregnant right away are more likely to tear open their uterine scar, rupture their uterus.

But babies need extra time too. We mentioned breastfeeding, but there's also very important mom time that helps with language development and emotional development. Some studies suggest that the ideal spacing for babies is three years apart. Kids should be able to walk, talk, feed themselves, and other important bodily functions before they face competition from another kid. Kids born closer than three years apart are less likely to be reading-ready when they start for school. So why should you think about planning for your next baby right after you've had one, and what can you do?

Number one. If you don't do something, you could get pregnant as soon as 28 days after delivery. This is the earliest that non-breastfeeding women can ovulate after the delivery. Babies born within the same year are affectionately called 'Irish twins'.

Two. You could use breastfeeding as your contraceptive method, but you have to breastfeed exclusively. No bottles, no formula, no food, no juice, no sleeping through the night.

Three. If you're sure that you've finished your family, you can consider having your tubes tied while you're still in the hospital; sometimes, within hours or so of delivery. Of course, you can send your man to have his tubes tied while you're recovering in the hospital from your delivery.

Four. You can have low dose hormonal implant put in your arm in the hospital before you go home. It doesn't affect breastfeeding and it lasts three years.

Five is to have an IUD placed right after the baby and the placenta come out. If you've had a caesarian section, it can be placed right in the operating room, and then you don't have to think about it. You'll have 5 to 12 years of protection depending on what kind of IUD you choose, or you can it removed in a couple of years and plan your next baby.

Are there problems with putting in an IUD so soon? There's an increased chance that it might fall out. The uterus is big, the IUD is tiny, and the cervix is open from the birth. Your doctor should check when you come back for a visit that it's in the right place if you have it placed right after the baby is born. Another problem is not all doctors know how to do this, but we've been doing this at the university hospital for several years now. Insurances may not want to pay for a contraceptive method that usually is done in the clinic when it's done at the time of birth, but several states have taken steps to remove this barrier.

If you're interested in any of these options, make sure that you talk with your doctor or midwife during your pregnancy so they can be ready to get you what you need after you deliver. Putting some time between babies is good for moms and good for babies. Think about what you would like to do and talk about it with your health care provider when you're pregnant. We can give you options that are highly effective and highly reversible and highly forgettable until you're ready for your next baby.

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