What do you think of when someone says "birth control"? Chances are you think of a pack of pills. Or maybe you think of the ring and the patch, which are essentially pills delivered in other ways. When girls and women come to my office looking for birth control, they are usually thinking of pills. And in the past, I was right on board with recommending them unless there was a reason not to, such as a medical condition that made estrogen unsafe. But several years ago, with the help of the World Health Organization counseling form, I totally changed my approach to how I talk about birth control, especially for young women.
I am seeing young women in my office who are attending college and are looking for options to prevent pregnancy. When they come to see me, I will ask them: What is the most important feature of a birth control method for you? I hope they all answer with one word: effectiveness. While safety, lack of side effects and ease of use are all very important, effectiveness is the top priority if you don't want to become pregnant.
What many people don't know is that pills are not the most effective type of birth control -- especially if you may not remember to take them every day. Realistically, the chance of pregnancy using pills is about 9 percent, which means 9 in 100 women will become pregnant each year while using birth control pills.  Today, other methods are available with much lower pregnancy rates. And isn't that what birth control is all about?
Taking a Fresh Look at LARCs
The most effective reversible (non-permanent) birth control methods are long-acting reversible contraceptives, or LARCs, which stay in your body for a given length of time. For all of these, the chance of pregnancy is less than 1 percent a year, well under that of pills.  LARCs include the subdermal implant (Nexplanon) and intrauterine devices (IUDs, Mirena, Paragard, and Skyla). Many of these have a bad reputation based on outdated research, so let's examine the accurate facts about each option.
Nexplanon is a rod about the size of a small matchstick that is inserted under the skin of the upper inner arm in a doctor's office using just local anesthesia. The insertion process takes less than five minutes. Each day for three years, a small amount of progestin hormone is released from the implant, circulating through the body and preventing conception. And the best part? You don't have to remember to do anything except swap it for a new one in three years. When you want to get pregnant, or if you don't like the implant, it can be removed in the office. As with the Depo-Provera shot, Nexplanon users don't usually have regular periods. Bleeding may be sporadic and unpredictable, but is usually not heavy.
Intrauterine devices (IUDs) are small T-shaped plastic inserts that are placed into the uterus in the office by your doctor or advanced practice nurse. A plastic string comes off the bottom of the T and extends about an inch into the upper vagina. The IUD works by preventing sperm from reaching the egg. People who don't want to use "post conception" methods will be happy to know that the number of pregnancies lost after fertilization is much lower with the IUD than on cycles where birth control isn't used. If the woman is happy with the method, the IUD can be swapped for a new one every three to 10 years (depending on the type).
Not Your Mother's IUD
IUDs got a bad rep in the '70s when the Dalkon shield was found to cause pelvic infections, infertility and chronic pain due to a poorly-designed string which allowed bacteria to travel into the uterus. Design changes have almost eliminated these risks. Those who are most informed -- including many gynecologists -- choose the IUD as their preferred birth control method.
The Mirena (up to five years) and Sklya (up to three years) both release a small amount of progestin hormone into the uterus each day. Very little hormone reaches the rest of the body, so even girls and women who can't take oral or injectable hormonal birth control usually don't have problems with these hormone-secreting IUDs. In the first four to six months, bleeding can be irregular and annoying. After that, most users have either no bleeding at all or a light period once a month. Mirena is appropriate for most girls and women, while Skyla is specifically designed for use in those who have never given birth. Mirena and Sklya are particularly good for girls and women who suffer from menstrual cramps or heavy periods.
The Copper T IUD (Paragard), which lasts for up to 10 years, has a small amount of copper on it that is toxic to sperm without the need for hormones. Women often choose the Paragard for its 10-year effectiveness and lack of hormones. The Paragard is the only LARC where you can expect regular predictable periods, although they may be heavier and you may experience more cramping than usual.
Get More Information
If you follow 1,000 couples who are having sex regularly without birth control, about 850 will be pregnant in a year. On pills, about 90 in 1,000 couples will be faced with unplanned pregnancy. With LARCs, and depending on the method, that number drops to about three. 
LARCs may not be the right option for everyone, but more young women should consider them, given their effectiveness. All choices come with risks and benefits. If you care about your method's effectiveness, talk to your health care provider about which LARC might be right for you.
 Association of Reproductive Health Professionals
Long-Acting Reversible Options Beat Pill, Study Shows
New England Journal of Medicine article on LARCs
Decision tool by Association of Reproductive Health Professionals
U.S. Selected Practice Recommendations for Contraceptive Use, 2013 (Centers for Disease Control and Prevention)
Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy (The American Congress of Obstetricians and Gynecologists)
Association of Reproductive Health Professionals patient resources
Planned Parenthood Birth Control