We're moving! Get our latest gender and identity coverage on washingtonpost.com.

The side effects started three days after Ava Frankel took her first birth control pill.

First came the waves of nausea. Then her mood started to shift. She didn’t feel any more depressed or anxious than usual, she said. She just felt “numb.”

She persevered for two months, she said, before deciding the pill wasn’t worth the side effects. An 18-year-old college student, Frankel downloaded a menstrual cycle-tracking app on her phone, relying on natural family planning and the “pull out” method for almost five years.

Last year, at age 23, Frankel asked a doctor to prescribe a new non-hormonal birth control gel, Phexxi, which came on the market in September. Inserted with an applicator before you have sex, Phexxi is designed to maintain the normal pH levels inside the vagina, keeping it acidic to create a less hospitable environment for sperm, which prefer less acidic environments. Effective immediately, Phexxi keeps the pH levels low enough to prevent pregnancy for up to an hour.

“I went to the bathroom 15 minutes beforehand and put that bad boy in,” said Frankel, who now uses Phexxi regularly and has invested in the product. The experience has been a “game changer” for her, she said. No more relying on a man to wear a condom or pull out when he promised to.

“The first time I used it I was like, ‘Wow. I get to rely on myself.’”

For many who menstruate, hormonal birth control is not an option. Any method that inserts synthetic hormones into the body — the pill, the Depo-Provera shot, a hormonal intrauterine device — might be incompatible with an existing health condition, or cause side effects that alter other aspects of a woman’s life. Non-hormonal options are very limited, said Sheila Mody, an OB/GYN at the University of California in San Diego, who works in a complex contraceptive clinic, serving people who have struggled to find a birth control that works for them. Phexxi and other contraceptive gels in development offer a completely different approach to birth control, she said.

“We should feel excited about this,” said Mody, who started prescribing Phexxi six months ago. “Phexxi has given us a novel way to prevent pregnancy.”

Some people might decide against Phexxi because of its efficacy rate, Mody said. With typical use, the gel is approximately 86 percent effective at preventing pregnancy. That’s more effective than a condom (85 percent), but lower than the pill (91 percent) and significantly lower than an IUD (99 percent). Developers of similar non-hormonal gel, Oui, say they expect a higher efficacy rate — but Oui, still in preclinical trials, is probably three to five years away from approval by the Food and Drug Administration, according to Thomas Crouzier, co-founder of Cirqle Biomedical, the company behind Oui.

Because Phexxi is so new, access can also be an issue. Some insurance companies don’t yet cover it, Mody said, and pharmacies might not have it in stock. Mody says she finds pharmacies can usually get the product within a couple of days.

Anne Burke, an OB/GYN and director of the family planning division at Johns Hopkins University School of Medicine, said she has been seeing more patients who want a non-hormonal form of birth control. While some experience physical side effects like nausea and irregular bleeding, she said, others just “don’t want to use something that sounds so medical or synthetic.” While Burke doesn’t often see patients who experience mood changes from their birth control, she said, sometimes it can happen.

Catherine Boisvenu, 29, always knew she was going to have a hard time with hormonal birth control. With polycystic ovary syndrome and a history of severe migraines, her doctor warned her that many options would not work for her. She recommended the Depo-Provera shot, which you get every three months and contains no estrogen, important with Boisvenu’s existing health conditions.

Within two weeks of getting the shot, Boisvenu started having mood swings. She would spend all day in her bed, she said, crying. “It really freaked my family out,” Boisvenu said. Her periods also changed, she said, with frequent spotting between cycles.

She started thinking about other non-hormonal options, but none of those seemed promising either. There’s Paragard copper IUD, known to increase the length of and heaviness of your period, or the diaphragm, which can be difficult to use.

A year later, Boisvenu told her doctor she wanted to get her fallopian tubes tied. Her doctor refused, she said, telling Boisvenu that she might decide she wants to have children.

“It’s insane that I have to either change the hormonal makeup of my body or have something implanted in me in order to not have children,” Boisvenu said.

If men could have children, she said, she feels sure there would be better non-hormonal options.

Mody suspects men would be less willing than women to put up with the side effects of contraception. While many women are calling for male birth control, Mody said, there hasn’t been much movement on the research. “We only have the two extremes: condoms or a vasectomy,” she said. Researchers at Rockefeller University have been working on a gel for men, she said, but that’s still in development.

One benefit of Phexxi, and other non-hormonal gels, is that you only use it when you need it, said Siripanth Nippita, an OB/GYN and director of family planning at New York University’s department of obstetrics and gynecology.

“I’ve certainly had patients who would prefer not to have to take steps to keep their birth control going when they’re not having sex,” Nippita wrote in an email. On the flip side, Nippita said, you have to think about your birth control in the moment.

Each method of birth control has its benefits and downsides, Nippita said.

“If there were a perfect method, we’d all be using it.”

While Phexxi is a promising development, there is still much more work to be done on non-hormonal birth control, Mody said. In the next 10 years, she said, she’d like to see another non-hormonal IUD option, with fewer menstrual side effects than the copper IUD.

Boisvenu was happy to hear about a new non-hormonal gel, she said, but she won’t be trying it herself.

Inserting “goo” into her vagina just “doesn’t sound appealing,” she said.

Unless researchers come up with a “less invasive” option, she said, she would rather get her tubes tied.

Correction: An earlier version of this story misstated Thomas Crouzier’s title.

For this 24-year-old, fighting for Palestinian rights is ‘the most core part of my identity’

Lea Kayali is one of many Palestinian women continuing a long-held tradition of fighting for liberation

Editor’s Note on gender and identity coverage

We are excited to announce a new gender and identity page on washingtonpost.com

What does it mean to come together as Asian American women? This group has been seeking an answer.

The Cosmos was formed in 2017, and its future hangs in the balance