Sex talk: Common misunderstandings doctors confront about preventing pregnancy
Sex is one of the most natural things in the world—none of us would be here without it. Yet there are many things about sex that need to be learned. Even today, 60 years after the introduction of oral contraceptives, almost half of pregnancies worldwide are unintended. Avoiding pregnancy takes planning, and health professionals can do a lot to help patients better understand contraception.
As an academic physician, I teach an annual course at the Indiana University School of Medicine called "Sexuality for the Clinician," an important topic often not well covered in medical schools. In my classes, medical students report misunderstandings they encounter among patients about various topics, including contraception.
Some of these wrong ideas are mentioned year after year, and correcting them presents a prime opportunity to enhance sexual health. Here are four common ideas about contraception that are incorrect, each representing a real patient's story.
The pregnancy test of a patient in her 20s came back positive. She protested to her physician that she couldn't be pregnant. Her physician asked what form of contraception she and her husband had been using. She responded that they scrupulously avoided sex during her "fertile time." Upon further questioning, the patient revealed her understanding that pregnancy could only occur on a single day each month.
In reality, assuming a woman has a 28-day menstrual cycle, there are about six days during each cycle when sex can result in pregnancy. While a woman's egg retains its fertility for up to 24 hours after ovulation, the release of an egg from the ovary, sperm can remain viable in the female reproductive tract for up to five days.
This means that patients employing the so-called "rhythm method," one of the least reliable forms of contraception, need to avoid sex for at least six days in the middle of each cycle.
A teenager using oral contraceptives became pregnant. When her physician asked how she had been taking her pills, she said that whenever she missed a pill, she would double up the next day. Once she missed taking her pills for five consecutive days. So, on the sixth day she took six pills.
One way to help patients use medication properly is to explain how it works, including why they need to take it regularly. In this case, providing the patient with a basic explanation of how oral contraceptives work could be beneficial.
While there are different types of "the pill," most contraceptives work by preventing ovulation. The brain's pituitary gland, the so-called "master gland" of the hormonal system, detects stable high levels of the pill's ovarian hormones in the blood. As a result, the hormone that stimulates ovulation isn't released. But a pill must be taken every day to keep levels sufficiently high to prevent an egg from being released.
A new mother with a four-month-old baby expressed her fear to her doctor that she was pregnant again. How could this be, she asked, since she had been breastfeeding her baby since birth? The patient was correct that breastfeeding can suppress ovulation, but only if breastfeeding is frequent enough.
As it turned out, while the patient had been breastfeeding her baby since birth, she had also been feeding the baby formula, limiting breastfeeding to two or three times each day. In addition, her menstrual cycle had resumed the previous month.
Breastfeeding can be effective as a means of contraception in the first six months after birth. The hormones produced by the mother's body during breastfeeding naturally suppress the pituitary gland's secretion of hormones necessary to ovulate.
However, the baby must be exclusively breastfed and feed at least every four hours during the day and every six hours at night. Otherwise, breastfeeding will not adequately suppress pituitary secretion, and pregnancy can occur.
Sexually transmitted disease
A teenager came to a sexual health clinic complaining of symptoms of itching, rash and painful urination, which her physician suspected was the result of a sexually transmitted infection.
When her doctor asked her about contraception, she reported that she was "on the pill." Therefore, she said, she could not have an STI.
Many patients mistakenly assume that, in addition to preventing pregnancy, contraceptives can prevent STIs. While oral and other types of contraceptives, such as IUDs and hormonal implants, are usually highly effective in preventing pregnancy, they do nothing to reduce the risk of STIs.
The only widely used form of contraception that reliably prevents STIs is the condom. It creates a barrier between the skin and bodily fluids of sex partners. To prevent infection, condoms need to be used in addition to other forms of contraception.
Sex and medicine
These are a few examples of common misunderstandings that patients may harbor about contraception. Others include the idea that pregnancy can occur only if the woman has an orgasm, if sex occurs in certain positions or if the woman refrains from various cleansing practices, such as douching or taking a shower. In fact, none of these situations is likely to alter the probability of pregnancy in a reliable way.
Misunderstandings about sex include not only contraception but topics such as sexual response, sexual dysfunction and sexually transmitted infections. Such misconceptions serve as stark reminders that many people have not been well educated about essential aspects of sexual health. Families, schools and health professionals have a lot of work to do.