Today, ABC Life published a journalism piece titled “Before You Try Fertility Awareness Methods For Contraception, Here’s What Doctors Want You To Know” which quoted statements from doctors Melissa Kang, Amanda Newman and Black along with editorial by Grace Jennings-Edquist. You can read it here.
The piece concerned me on multiple levels and I felt compelled to write this letter in the hopes that medical professionals are able to provide more accurate information in future. With growing rates of women interested in pursuing less-invasive forms of contraception, I think it is important that we can expect comprehensive, transparent and unbiased information about Fertility Awareness-Based Methods from our primary healthcare providers.
The editorial piece by the ABC focused disproportionately on negative aspects of FABMs, and did not provide accurate or comprehensive information about effectiveness rates. It also provided a misinformed picture of what everyday use of a FABM would look like for women, and displayed a lack of understanding about the importance of cervical fluid by seemingly focusing only on the importance of temperature.
Most disappointingly, it showed a distinct bias against FABMs and did readers a massive disservice by not allowing them access to all of the facts so that they might make their own fully-informed decisions.
My main concerns are outlined below as responses to specific quotes:
“The main drawback of these methods: They’re generally less effective than hormonal methods of birth control, because they’re just so damn hard to get right.”
The Symptothermal Method of Fertility Awareness is very simple and easy to use and learn – if you are a strong candidate for the method.
Success relies upon the accuracy of the method itself, the ability of the user to correctly apply the rules, and the willingness of the couple to adjust their sexual behaviour during the fertile window.
In addition, the largest study on the Symptothermal Method was based on those who were practising under the guidance of an instructor – learning with an instructor instead of self-teaching means that the Symptothermal Method need not be “damn hard to get right”.
Finally, we might do well to give women a little more credit for their intelligence. Surely it’s not just me that’s getting tired of this outdated rhetoric being dragged out every time it’s suggested that women might take charge of their own health and wellbeing? These sorts of attitudes seem very prevalent in the medical system where women are reporting gaslighting in disproportionate numbers, have been proven to have to wait longer than men in the ER and be less likely to receive pain killers, and where those with endometriosis are waiting up to seven years for a diagnosis.
With the right support, we are more than capable of learning how our fertility cycle functions. Checking your cervical fluid for 5 seconds when you go to the toilet and taking your temperature for 30 seconds in the morning is not a hard task and is a great fit with many lifestyles. Interpreting your charts does take time to learn but that’s why we have so many great instructors to work with. You can find an instructor to work with by clicking here.
Of course, the Symptothermal Method is not a good fit for every woman, but a good instructor will identify very early on if this is the case and can then recommend that you choose a hormonal or LARC (long acting reversible contraceptive) option.
“The effectiveness of fertility awareness methods is quoted between 75 and 99 per cent, but the sympto-thermal method is thought to be more effective,” says Dr Kang. “The exact rates aren’t really known.”
The symptothermal method has been proven (via a prospective clinical trial) to be up to 99.6% effective with perfect use. This study followed 900 women over 17,638 menstrual cycles and was published in 2007 in the journal of Human Reproduction. Participants were using the Sensiplan Symptothermal Method and were using it under the guidance of an instructor. You can read about this study here: https://www.ncbi.nlm.nih.gov/pubmed/17314078
Typical use rates are less clear. The typical use rate published in the above study was 98.2%; however, typical use rates should ideally be calculated via population based surveys so that they are better reflective of a larger swathe of user demographics and therefore more generalisable to everyday life. The typical use rates we use for most contraceptives are obtained from the U.S. National Survey of Family Growth (NSFG). Rates of use for individual FABMs are too low for the NSFG to provide statistically-accurate typical use rates for each method. Instead, the NSFG provides an overarching typical use rate for all FABMs. Unfortunately, over 80% of survey respondents actually reported using the Calendar Rhythm Method, meaning this overarching typical use rate is skewed downward (and obviously obscures the individual use rates of different methods such as the Symptothermal Method).
In fact, Contraceptive Technology recently tweeted about this and you can read that tweet here: https://twitter.com/ContraceptTech/status/1102952910546259974
The overarching typical use effectiveness rate is estimated to be 85% for all FABMs as published in the most recent 2018 edition of Contraceptive Technology. You can read more about this in a blog post by Dr Chelsea Polis who is a leading epidemiologist with a special interest in the field of FABMs: http://chelseapolis.com/blog/understanding-effectiveness-estimates-for-fertility-awareness-based-methods-of-contraception
All this to say – exact rates for perfect use of the Symptothermal Method ARE known and they are shown to be up to 99.6% effective. Exact rates for typical use are estimated at 85% effective but this is an overarching figure that is skewed downward – as explained above.
“”The problem is that I don’t know anybody who’s perfect and you probably don’t know either,” says Dr Newman. For that reason, “if you don’t care if you get pregnant or not, it’s fine, it might delay it,” Dr Newman says — but she wouldn’t recommend it for women who certainly don’t want to fall pregnant.”
I find this statement problematic. I certainly don’t know a single person who is perfect! And yet all of us non-perfect humans are out here using contraception on a daily basis. While this is not such a huge issue for LARCs (long acting reversible contraceptives such as IUDs and implants) where typical and perfect use effectiveness rates are essentially the same, I wonder whether Dr Newman makes the same remarks about the Pill, the Vaginal Ring, the Patch, Condoms and Diaphragms? All of the above methods have typical use rates that are much lower than their perfect use rates and yet they are used by millions of non-perfect humans around the world every day. I find it problematic that medical professionals appear to hold FABMs to higher standards than they do other methods of contraception.
“And there is absolutely no doubt that if you really want to avoid an unplanned pregnancy, then natural methods are really not the way to go.” Dr Black agrees, adding: “They’re not cost-effective, those methods, because the cost of unintended pregnancy is very high and very frequent with those methods.”
This statement is reflective of a very strong bias against FABMs or “natural methods”. I would encourage Dr Black to educate him/herself about the actual rate of unintended pregnancy that users can expect when using the Symptothermal Method – as discussed in preceding paragraphs. When counselling patients on contraceptive options, it is important for medical professionals to remember that effectiveness rates are not the only points a patient will be considering. For many women who ‘really want to avoid an unplanned pregnancy’ – there will be other criteria that are just as important, such as avoiding side effects.
I can speak from personal experience here as a Symptothermal Method user who began using the method in 2016. It was absolutely out of the question for me to fall pregnant at that time, but I was also adamant that I did not want to have synthetic hormones circulating in my bloodstream, nor a foreign medical device inserted into my uterus. With all these factors taken into consideration, the Symptothermal Method was the best choice for me… just like it would be for so many other women who never get the chance to hear about it due to bias and lack of education from their primary healthcare provider.
“Fertility awareness methods are very hard to get right for women who have irregular periods — and irregularity can be caused if “you’re stressed, because you’re travelling, you’re unwell, you’ve got a cold or something,” says Dr Newman.”
FABMs work exactly the same way whether you have a textbook 28-day cycle or a 150-day cycle caused by PCOS. They still provide the same information – they alert you to the opening and closing of your fertile window and what you do with that information is up to you. However, long cycles will involve extended periods of either abstinence or barrier use (such as condoms), and this can be a very unattractive option for many couples. In this way, irregular cycles can be charted perfectly accurately with a FABM, but the couple should be comfortable with extended periods of condom use or abstinence. If using condoms for weeks or months on end (depending on the length of the cycle) is not an attractive option, then it would be advised that the couple should choose a different method of contraception.
“If you get icky about words like ‘mucus’ and ‘cervix’, these methods won’t be for you, as they require getting pretty up close and personal with your body.”
I don’t exactly have an issue with this statement as it is true that many women won’t be comfortable with the level of scrutiny required to accurately use the Symptothermal Method. What I do have an issue with is that the flipside of this statement was never offered – that cervical fluid is an absolutely fascinating hydrogel that provides a wealth of information about your fertility status. Understanding how this fluid changes throughout your cycle can provide women with a huge boost of confidence and body literacy. You can read about how cervical fluid works by clicking here.
Understanding how cervical fluid operates can also erase misguided concerns about “vaginal discharge” – many women spend years of their lives concerned that they have vaginal infections when they are really seeing perfectly healthy cervical fluid. Using a FABM can also mean reassurance for many women who might be curious or worried as to whether they are ovulating. Emphasising the incredible benefits of the level of body literacy that FABMs promote would have been a fair inclusion in this article. Instead, it seems the author chose to focus on the negatives – which really only apply to a small group of women who are uncomfortable with getting acquainted with their own cervical fluid.
“If a couple is highly motivated to use a fertility awareness method, “they need to learn to do this properly, and that means learning how to take your temperature accurately and every day,” says Dr Newman.”
This statement again shows a lack of understanding of the Symptothermal Method. The Symptothermal Method requires users to track both temperature and cervical fluid, and in fact it is cervical fluid tracking which can be most confusing for new users. In many cases, understanding how to track and chart cervical fluid is more important than temperature. This is because cervical fluid is influenced by rising oestrogen in the lead up to ovulation. It therefore acts as a warning to the user that ovulation is approaching. Temperature only rises after ovulation, meaning it is a great way to confirm that ovulation has already occurred, but doesn’t give the user any useful information prior to this. This is important because sperm can survive up to 5-7 days in the reproductive tract meaning you need to have at least this many days’ warning that ovulation is approaching.
“And keep in mind that fertility awareness methods involve abstaining from sex for the at-risk days.”
This statement only applies to those with a religious reason to avoid the use of barriers. The rest of us? We’re getting down and dirty with barrier methods of contraception during our fertile window – and enjoying stress-free unprotected sex during the rest of our cycle. Barrier methods of contraception can include condoms (male or female), diaphragms, cervical caps and more. For most of us, this is a very small price to pay to be able to enjoy unprotected sex during the rest of our cycle, free from any side effects of our chosen contraceptive. Those who practise a FABM are very aware that barrier use during the fertile window means that we are relying on the effectiveness of the barrier method as opposed to our chosen FABM during this time. In saying this, some studies appear to show that FABM users experience higher effectiveness rates than expected when using barrier methods. The largest study on the Symptothermal Method showed that barrier-users experienced a 99.4% perfect use effectiveness rate while abstinence-users experienced a 99.6% effectiveness rate.
Here’s hoping we will see a more informed and well-rounded piece on FABMs by the ABC in future. I would also hope that doctors Melissa Kang, Amanda Newman and Dr. Black will aim to provide less biased guidance to their patients when counselling on contraceptive options.
