Non-hormonal birth control

Are you considering natural contraception? You're not the only one. Some 14% of young women use a natural method according to research by Dutch Institute Rutgers. In this article, I talk about natural birth control, how GPs deal with this question, different methods of nonhormonal birth control and my own experience.

Young woman taking her temperature with a thermometer
Tracking your temperature is part of many natural birth control methods

Non-hormonal birth control

Wat is hormoonvrij? Dat is een anticonceptiemethode zonder extra (synthetisch) oestrogeen of een progestageen. Geen (mini)pil, prikpil, hormoonstaafje, pleister, ring -of hormoonspiraal dus.

There could be all sorts of reasons why you don't want or shouldn't use a hormonal method. Maybe you experience side effects. Or you don't want an increased risk of certain side effects. Or maybe you want to keep getting your period every month. Experience the normal ups and downs of your cycle. Stay in control yourself...

Side effects of the birth control pill

The number of women using the birth control pill has been declining for years. Fortunately, it is no longer not-done om te zeggen dat je als vrouw bijwerkingen ervaart van de pil. Ook psychische klachten: zoals somberheid, angst of een verminderd libido. Deze worden (hopelijk) niet meer aan de kant geschoven zoals vroeger het geval was. Of je hebt een arts die nog steeds niet op de hoogte is van de invloed van de pil op de hersenen en de hormonen. Zo kan je een afgevlakte cortisol respons hebben na een stressvolle situatie als je de pil gebruikt.

Sommige artsen wuiven deze klachten nog steeds weg als ‘misinformatie’. En het is waar: in onderzoek met grote groepen vrouwen zijn er geen duidelijke verschillen tussen pilgebruikers en niet-pil gebruikers als je het over psychologische bijwerkingen hebt. Behalve boven de 40 jaar. Dan zijn er mogelijk wél meer bijwerkingen. Dit onderzoek is nog in ontwikkeling. Wuif je als arts de klachten van deze vrouwen weg? Dan vind je dit soort (onvolledig) onderzoek dus belangrijker dan de ervaring van de vrouw zelf én de bekende hormonale veranderingen die de pil in het lichaam te weeg kan brengen.

Birth control consultation with your GP

It is not surprising that some women are dissatisfied with consulting their GP about birth control. In another Dutch study by Dutch Institute Rutgers 59% of women felt comfortable in an initial consultation. I don't think that's very high. Only 17% indicated that there was shared decision-making.

Talking to your GP about non-hormonal birth control methods

Do you also turn off when your GP only wants to talk about the reliability of a natural method? You are not alone. From another study GPs, when asked about non-hormonal birth control such as an app, only wanted to talk about the risk of pregnancy. That, of course, needs to be minimised... so for GPs, a cycle tracker as a method of birth control is not an option. Not safe at all. So as a young woman, how can you feel heard? The GP no longer talks to you, he or she only acts like a stern mother who wants to protect you from an unwanted pregnancy.

And when they do talk about a natural method, it is invariably mentioned that it requires so much discipline (are women not disciplined enough?), that so many factors can affect your temperature (can't women learn about those factors?) or that if you are young you should absolutely avoid pregnancy at all costs.

There is always a possibility you will get pregnant

Welke methode je ook gebruikt, er is altijd een kans op een zwangerschap. Die kans wordt groter als je een methode niet goed gebruikt. En dat komt veel voor in de praktijk. Dat geldt voor de pil, het condoom en ook voor de natuurlijke methode. Alleen voor een spiraal of hormoonstaafje geldt het niet. Als die eenmaal zit, kan je namelijk zelf niet zo veel fout doen (behalve vergeten het vacuüm van je menstruatiecup er af te halen voordat je deze verwijdert waardoor je de spiraal er deels of helemaal uittrekt).

Is reliability most important to you?

Is the highest possible reliability the most important thing for you? How bad would it be if you did get pregnant? How do you feel about using the abortion pill if you are a few days overdue?* After all, if you use a natural method such as an app, you will quickly realise you are pregnant. It doesn't take long, or the Dutch GP may also soon prescribe the abortion pill.

If you want to use a natural method, that's totally okay. It's your body, your choice, your responsibility. I hope your GP listens to you, doesn't dismiss complaints from the pill and informs you well about all birth control methods.

*not that I'm suggesting the abortion pill as a birth control method. But what if the method that suits you best gives a 5-7% probability of pregnancy a year? You are 1 of those 20 women who got pregnant anyway. If you really don't want a child right now, but are willing to take the abortion pill, this might also be an option for you.

My own experience with nonhormonal birth control

For me, it started 12 years ago when I read the book Taking Charge of Your Fertility by Toni Weschler. It would take three months to be allowed to use on the method, according to Toni. You read it right: a three-month learning curve, in other words! With the bonus of learning more about your own cycle, knowing when your ovulation is, your fertile days, your grumpy days right before your period... more in touch with your body in other words. In the 10 years I have been using the sympto-thermal method, I only got pregnant when I wanted to. So you can say I am satisfied with this method!

The sympto-thermal method

Toni's method is one of the sympto-thermal methods. The most reliable natural method. It also scores highly compared to other non-hormonal birth control methods. When using this method, you rely on your cervical mucus ('sympto' of symptom) and your morning temperature ('thermal'). You need that three-month learning curve because quite a few things can affect your temperature, your ovulation and thus your cycle length and thus the reliability of the method. But once you get the hang of it and understand how it works, that need not be a hindrance.

You track your temperature every day and if there is a crazy reading in between, you scratch behind your ears first. Looking back at my tracked readings, there is indeed the occasional 'crazy' reading in between. It was the weekend and I had slept in: a higher temperature. On the contrary, I got up very early: a lower temperature. My cycle was usually 29 days, but sometimes 25 days and very occasionally 35 days. No problem: I could easily predict that by looking at my temperature curve. 

Sometimes experts say that the variation in body temperature makes the method unreliable. But that need not be a problem at all: in fact, you can learn how to deal with this!

In the Netherlands, there is Sensiplan. They talk about a high reliability, around 98.2%. But only if you take their Sensiplan course, which also happens to last about 3 months. So however you approach it, allow yourself 3 months of 'learning time'. During that time, you will also find out if the method is really for you.

Could the sympto-thermal method be any more reliable?

In de sympto-thermale methoden heb je altijd twee niet-vruchtbare fasen: een korte fase aan het begin van je cyclus, nog ver voor je ovulatie. Dit is tijdens je menstruatie en ook een paar dagen daarna. En een fase na je ovulatie. De niet-vruchtbare fase na je ovulatie is makkelijker te bepalen dan die fase daarvoor. Je hebt geen vruchtbaar cervixslijm meer (dit heb je wel gehad) en je temperatuur is al een aantal dagen hoger dan eerst. Je bent ook zo halverwege je cyclus. Theoretisch wordt de sympto-thermale methode betrouwbaarder als je alleen in deze laatste fase onbeschermde seks hebt.

Other natural methods

Cycle trackers

Digital cycle trackers such as the Daysy® and Lady-Comp®, among others, measure your temperature and work with an algorithm. They claim their method is 99.4% effective. So 99.4% reliable you might think. Well, no. The study behind this figure has been withdrawn due to all sorts of shortcomings. For example, read this critical article.

There is a new study with this same number (how coincidental?). The number 99.4% indicates how often the app correctly indicates a predicted non-fertile day before de ovulatie ook echt een niet-vruchtbare dag was. De niet-vruchtbare dagen voor de ovulatie worden voorspeld op basis van eerdere cylci. Pas achteraf weet je of de voorspelde ovulatie ook echt klopte. Soms is de ovulatie vroeger en dat is een probleem: een niet-vruchtbare dag wordt dan een vruchtbare dag. Je kans op zwangerschap wordt dan een stuk groter! Volgens deze studie is deze fout maar 0.6% bij normale cycli. Bij een korte of onregelmatige cyclus was het getal wel wat hoger.

Unfortunately, this study is not about how many women actually got pregnant when using this method. In fact, women who got pregnant did not even participate in the study. So you can't say that the Pearl index is 0.6 (like many online blogs, which blindly copy the number and also give you a nice discount). That has not been researched at all! So what are the chances of pregnancy when using this method? According to Rutgers, temperature methods normally give a 10% chance of pregnancy per year.

The algorithm probably does lower this probability, but I would be surprised if in practice it is 2% or less. So keep in mind that there is still a chance of 5-7% (I'm taking a guess!) that you will get pregnant using this method. Of course, that may still be acceptable to you. You can also theoretically make this method more reliable by using only the non-fertile days after ovulation. Especially if you have a short cycle.

Pessary, withdrawal, the condom and the copper IUD

There are also natural contraception methods that do not require you to keep track of your temperature. The diaphragm is a kind of protective cap you have to place over your cervix with spermicidal gel. How exactly to do that you won't have figured out in one go. According to the manufacturer Caya®, you need 1 month to teach yourself this. After sex, you should leave the diaphragm in your uterus for 6 hours. When used properly, the reliability is 4% but in practice is rather 16-17% according to Rutgers.

The withdrawal method oddly enough has the same reliability as the diaphragm when used perfectly. Some 4%! However, chances are your partner won't be able to use the method perfectly (all the time) and then you understand that the chances of a pregnancy become a lot higher (towards the 20%). Possibly an option for some couples, though.

I shouldn't forget the condom, of course. Although not so popular among young men these days... I heard at a refresher course the other day. It remains a reliable method when used properly. The probability of pregnancy is about 1-2%. In practice, somewhat lower, at 13%.

The last option I would mention is the copper IUD. The risk of pregnancy is very low, at less than 1% per year. There is just a chance of side effects, such as more symptoms during your period.

And in the future...

Research, fortunately, is still contuining. A nonhormanl pill is coming. The drug mifepristone (a progesterone antagonist) could probably be used as a non-hormonal contraception once a week. But also as a morning-after pill (with fewer side effects than the two now on the Dutch market) and perhaps also as an early overdue treatment? Or only when you have sex occasionally? So many options... but more research is needed first. Read more at Women on Waves.

Mifepristone might also make it easier to opt for a natural method. You have a back-up. Of course, the taboo of becoming pregnant while using birth control has to dissapear. In fact, it must dissapear anyway, because with any method you always have a probability of getting pregnant. It is up to the woman to decide what she wants to do (her body, her choice).

Further reading

Trudy Dehue - Egg, foetus, baby: a new history of pregnancy

Many midwives can also give you (advice on) your contraception, even if you haven't been there before for more info on figures

Thanks also go to GP and sexologist Peuter Leusink's presentation and Dr Lotte Gerritsen's presentation at SCEM's 'Modern Contraception' conference, which took place on 18 January 2024.

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