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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.

If you are considering having breast implants, for whatever reason, how do the new FDA guidelines on breast implants affect you and your decision?

Breast augmentation is near the top of the most cosmetic surgical procedures. Although the number of women who had breast implants fell by one-third in 2020, probably related to COVID-19 pandemic, still 200,000 people had breast implants in the U.S. in 2020, down from the usual 300,000 implants per year. About 75% of the implants are for cosmetic reasons, and the rest are part of reconstruction after breast cancer surgery.

Recently, the FDA took some new steps to improve and strengthen the information guidelines about implants and short- and long-term consequences.

It's hard to know how women want to receive information about the risks of breast implants. They believe that they know the benefits, at least for the persons they believe themselves to be right now. They can't really assess the benefits to the woman they will be at, let's say, 60. However, the assessment of benefits is a completely personal process and will be different from woman to woman. And this includes trans women making the decision to have breast implants.

The risks are harder to communicate. Language is often very medical, numbers are hard to process, and some people don't even want to know the risks.

There are data from a randomized trial of information giving that women who received more information were happier with their decision, were less likely to experience preoperative anxiety, and were less likely to experience postoperative regret. So in the information era, I think more is better.

So what are the new components of these new FDA guidelines? First of all, they aren't exactly new. They've been worked on for several years now, and they went out for public comment and were published back in 2020. However, they became more official in the fall of 2021.

Firstly, the boxed warning, the ominous black box that comes on some package inserts of medications and devices that actually nobody really reads unless you stick it on their nose.

I'm going to quote here the example from the FDA with my own asides put in. "Warning," and this is in a big black box, "breast implants are not considered lifetime devices. The longer people have them, the greater the chances are they will develop complications, some of which will require more surgery.

"Breast implants have been associated with the development of a cancer of the immune system called breast-implant-associated anaplastic large cell lymphoma. This cancer occurs more commonly in patients with textured breast implants than smooth implants. Although the rates are not well defined, some patients have died from this." Okay, that's number two.

Three, "Patients receiving breast implants have reported a variety of systemic symptoms, such as joint pain, muscle aches, confusion, chronic fatigue, autoimmune diseases, and others. Individual patients' risk for developing the symptoms has not been well-established. Some patients report complete resolution of the symptoms when the implants are removed without replacement." Okay, that's the black box.

Well, I would want to know more about the phrase that the implants are not considered lifetime devices. There are no recommendations that breast implants be removed after some certain years, not like IUDs that have a finite effectiveness with recommendations for removal at a certain time.

Eighty percent of women who've had an implant placed still have it at 10 years. Of course, the woman that you are at 25 will not be the woman that you are at 55, and neither are your breasts, as all of us know.

"The chance of complication increases over time." What does that mean? Your surgeon should explain those complications, what they are, how often they happen, and what can be done about them.

The common ones are hard fibrous walls around the implant that can be unnatural-looking and feeling, or rupture of the implant capsule.

The uncommon one is the cancer that's associated with the certain kind of implant with a textured, not a smooth, outer covering. That cancer, which is mentioned in the black box, is called breast-implant-associated anaplastic large cell lymphoma. This is a mouthful, but is lymph cancer that arises over time, rarely.

The incidence in women who have these textured implants is 1 in 3,000 to 1 in 30,000. So it's not common. We have a great interview with Dr. Jay Agarwal on this kind of cancer and breast implants. You can find this interview at The Scope if you want to know more.

"Breast implants have been associated with these systemic symptoms." What does that mean? Some women have experienced symptoms such as pain, autoimmune symptoms, chronic fatigue. In the past, this has been somewhat ignored. But there are some women who've had fewer symptoms after their breast implants are removed. This isn't very well understood, but here it is in the black box.

To help understand the black box warning about breast implants, the FDA has created a model patient decision checklist. I think this is really great if it's given to the woman well in advance so she has time to read it or have someone read it to her and explain it to her. This isn't something to be handed out in the pre-op visit just to sign, the way you sign your permissions to your software like Google or your phone. This should actually be read word for word.

The FDA created this checklist to add to that surgeon's counseling. It is meant to be a springboard for discussion, and the patient will read and check off that they've read it and understood it.

It is long, multiple pages, with places for the patients to sign at the bottom of each topic. It includes who shouldn't have implants, at least at the moment: women who have an infection, women who are pregnant or breastfeeding, women who are having chemotherapy or have a suppressed immune system. It includes more information about the rare lymph cancer and about long-term systemic symptoms.

Actually, the example in the FDA guidelines is a really, really good one. If you're an information junkie like me and you read at, at least, the 12th-grade level, it's great.

The long-term risks of complications are spelled out. The frequency at which these things happen are attached, such as painful scar tissue around the implant reported in 51% of patients, rupture or leaking of the implant 30%, need for reoperation 60%. But those are just the biggies.

It's a really great document. It's what your surgeon should have been telling you anyway, but in the heat of the moment in the office, they might not take the 30 minutes to talk to you about this. And you might not remember. This is a great chance to take it home and read it carefully and bring it back with your questions.

And with the FDA guidelines, there's an updated suggestion about management of breast implant rupture or leakage, that 30% of the time it happens.

And last but not least, there's a card for the patient to keep forever in her wallet or personal records about what kind of implant she has, what it's made from, and when it was placed.

Now, you think you'll remember all this stuff, but you won't. And maybe you'll have them still at 80 and your memory is fading. Your surgeon may have retired or gone on to surgeon heaven. Your medical records may be lost. But at least you have a document about what is existing in your body.

If I had implants, I would laminate mine and put it next to my driver's license or my organ donation card.

I think these are really good steps in the right direction in patient information and decision-making. I know you just want what you want and you wanted it yesterday, but it's a long-term decision with long-term consequences, some good, some not so good. You should take your time and try to get it as right as you can.

Thanks for joining us on the "7 Domains of Women's Health" at The Scope.

Dr. Jones: The pill. Birth control day is November 12. A little history, a little information, and where we are going about contraception. This is Dr. Kirtly Jones from the Department of Obstetrics and Gynecology at University of Utah Health Care and this is The Scope.

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Dr. Jones: Whatever you think personally, the vast majority of women have had a moment, maybe a day, maybe a year, maybe a lifetime, when they didn't want to get pregnant. Throughout recorded history, women have tried all kinds of potions, positions, and procedures in an effort not to become pregnant. Some were a little bit helpful, some were really harmful, and some were just ridiculous. Barrier methods like condoms and diaphragms, methods used at the time of intercourse to block sperm from getting up to the egg, have been around for a long time, but using a method of birth control when you aren't really thinking clearly isn't so successful. IUDs have been around for a while but not in their current form.

In 1960, after years of animal and human trials, the hormonal birth control pill was available to women. The doses were high, about five times higher than current doses, the side effects were significant, and women were desperate to take the pill. The inventors created a birth control pill that would block ovulation but give women a monthly period. The monthly period was so women would know they weren't pregnant. Home pregnancy tests weren't available then. It was also formulated in the hope that the Pope would think it was natural and allow Catholic women to use it. Well, that didn't work so well, but Catholic women took the pill anyway, and it worked if you took it regularly.

But now, we are way beyond the pill for birth control. We know more and we have more choices. In thinking about birth control, some women think about effectiveness. Some women think about side effects and risks. Some women think about costs, and for some women, how it works matters to them, and women like me think about all those things. So, let's talk about birth control methods starting with what's most important to me, which is effectiveness.

Effectiveness is often presented in terms of the chances of getting pregnant in one year using a given method. There's a problem here. Women using birth control for many years, maybe up to 30 years, so methods that might have a chance of getting pregnant, so-called failure rate, of 10% per year will have a very high cumulative chance of getting pregnant over 10 years. Also, effectiveness or failure rate of methods often depends on the woman doing something. If she doesn't do it or do it correctly, it won't work. The method might be very good in theory but not so good in practice.

So, methods that work well and you don't have to think about include blocking a woman's tubes or a man's tubes, but this is permanent. The lifetime failure rate, lifetime, 30 years, of tubal ligation or vasectomy might be about 1%, not per year, but for lifetime, but it's not reversible and some people just don't want to have a baby now, but they'd like to have one later or at least keep their options open.

Methods that rarely fail that you don't have to think about and that are reversible include the IUD, one type with hormones, one type with copper, and implants that go under the skin in your arm, and that has hormones. They work from 3 to 10 years, depending on which one you choose, and are easy to remove. They have a failure rate of about 1%, one in a hundred, or less per five years of use, so that makes a pretty low failure rate.

Methods that are pretty good. Failure rate of 5 to 10% per year includes pills, patches, rings, shots. They all have hormones. They have some good things. They decrease menstrual flow. You can choose when to have your periods. They may decrease the risk of ovarian and uterine cancer, but you have to do something and sometimes women don't do those things. They don't take their pills. They don't remember to put their patch on. They forget to get their shot. So, the failure rate's up there in the 5 to 10% per year, and if you're thinking about not wanting a baby for 5 or 10 years, those little 5% add up.

>Methods that aren't so good but are better than nothing and might protect against sexually transmitted infections include male and female condoms, diaphragms, and cervical caps, along with vaginal gels and creams. Failure rates are about 10 to 30% depending on how you use them. If you use them exactly as you should, which is just when you're going to have sex, each time and every time, they work better, but human beings are human beings and each time and every time sometimes turns out to be some of the time.

Methods that don't use hormones or devices but use the timing of sex to avoid the fertile period can work very well. These are called abstinence-based methods. Both people have to agree to follow the rules, and you absolutely cannot break the rules or you'll get pregnant. This means abstaining from sex during your fertile period and being very self-aware about when your fertile period actually is. So, you have to follow the rules. If you follow the rules completely, the failure rate's 1 to 5% per year. If you follow the rules the way most folks follow the rules, the failure rate is 30% per year. There's a little joke. What do you call people who use abstinence-based methods? You call them parents.

So, there are going to be some new birth control methods coming up in the next five years, but they will fall into these groups. Highly effective, reversible, that you don't have to think about, like IUDs and implants, hormonal methods that you have to think about, and barrier methods. Birth control is highly personal. Though it seems as if some folks want to get into your business and into your bedroom, but you should be informed. Today we talked about chances of your birth control working for you, and you shouldn't take chances when it comes to making a baby. Stay tuned. We'll be talking about side effects, how methods work, and costs later on on The Scope.

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Interviewer: All sunscreens are not created equal. There are actually some that are better than others. We're going to find out more about that next on The Scope.

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Interviewer: Dr. Doug Grossman is an expert in early diagnosis and treatment of skin cancer at Huntsman Cancer Institute. All sunscreens are not created equal and I think I'm a little stressed out because I don't think I'm using the right sunscreen. Let's talk about that for a second. From my understanding, there are two different kinds of sunscreens.

Dr. Doug Grossman: There are actually a variety of products. A lot of patients like the sprays because they're easy to apply. The problem is you don't get enough of the material on the skin and so I also worry about if you're spraying a lot and inhaling.

Interviewer: I know. I was at the pool the other day and somebody was spraying and I was getting more in my lungs. My lungs were not sunburned after that.

Dr. Doug Grossman: Right, and some of these that have alcohol could also potentially be flammable, so that could be a risk as well. So I don't like the spray-ons. I do like the lotions that can be applied and as you indicated there are two basic types. The first are the mineral containing products that have either zinc oxide or titanium dioxide and these work as a physical UV blocker. The UV rays just bounce of these minerals and they stay on the skin, so they're very long lasting.

Interviewer: So kind of like a mirror?

Dr. Doug Grossman: Yeah and they block the entire UV spectrum. The other class of products which tend to be more popular because they tend to be less expensive and not leave as much of a white-ish residue on the skin are the chemical sunscreens and these work by absorbing the highest energy UV rays, so they prevent sunburn but some of the lower energy rays still get through and cause damage and they work again by absorbing so one they get saturated, then they loose their effectiveness, so they wear off very quickly, so you have to keep reapplying them.

Interviewer: So that's why you have to keep reapplying? So it's like if I tried to mix a lot of salt into water, eventually it can't absorb anymore. Is that kind of like the same thing?

Dr. Doug Grossman: Yeah.

Interviewer: Interesting. So if I don't know what kind of sunscreen I have, likely I have the chemical kind.

Dr. Doug Grossman: Yeah, most products in stores are the chemical base. There are a few products that contain the minerals that I recommend. My favorite product is Blue Lizard, it contain 15% zinc and titanium dioxide. I think that has the highest concentration of any product that I've found. It's made in Australia where they have the highest rates of skin cancer and it goes on a little white, but then it turns clear and I find that to be the most effective. There are several other products, Vanicream that has these sun blockers as well. And I know this from personal experience, these are the products that I use and I don't have any financial interests in these products?

Interviewer: You don't have stock, huh?

Dr. Doug Grossman: Correct.

Interviewer: I find that fascinating that the Blue Lizard that you talked about is from Australia where they have the highest incidences of skin cancer, so obviously they know what they're doing I guess.

Dr. Doug Grossman: I think so.

Interviewer: Yeah, so the other advantage to this from what I understand is you don't have to apply it as much either. It's like once on and you're good.

Dr. Doug Grossman: Right. Unless you're perspiring a lot and the skins getting wet and you're toweling it off, it stays on the skin and so you don't have to apply it nearly as often as the chemical based products.

Interviewer: So at the end of the day, these mineral based products may be a little bit more expensive, but you think they're well worth it.

Dr. Doug Grossman: Right, they definitely are more expensive, but you get what you pay for.

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