What You Want to Know About Birth Control Part One: The Pill

by Mona Saint MD

Since I receive so many questions on birth control, I have decided to do a series on the various birth control options available. In this issue I thought I would start with listing the different methods and then will discuss the birth control pill.

Fortunately, we are very lucky to have so many great methods available to us, compared to just 10-15 years ago. Currently in the U.S. the options include: barrier methods (such as condoms, diaphragms, cervical caps and sponges), combined oral contraceptives, the progesterone only pill (mini-pill), the emergency pill, the Ortho-Evra patch (a birth control skin patch), The Nuvaring (a vaginal ring), Intrauterine devices (IUD’s) including the Mirena and Paraguard devices, injectable contraception like Depo-Provera, Implanon (a rod that is inserted in your arm), and sterilization. One study ranked what they found as the most popular methods of contraception in the U.S (listed in order of highest popularity): birth control pills, sterilization, condoms, injectables and implants and patches (all tied), and lastly all other forms of contraception. (1)

In terms of ease of use, effectiveness and low side effects, I often recommend some of the newer low dose oral contraceptives (birth control pills) like Yaz, Yasmin, Orthotricyclen and Orthotryclen Lo, the Nuvaring, and the Mirena IUD. (By the way I have no affiliations with any pharmaceutical or other device companies, so my picks have to do with what patients do well on). However, there is not one option that is best for everyone and each person has their own preferences and issues to consider. Some factors to keep in mind when selecting contraception include, whether you want it permanent or reversible, whether you like taking a pill/patch/ring daily or weekly or not thinking about it for years, and how rapidly reversible you would like it. For instance if you are planning to have a baby, what is the horizon for when you want to conceive? Also, some people prefer to take a pill when they are taking their vitamins or brushing their teeth once a day, others cannot remember or dislike pills, and may prefer weekly patches, monthly rings, and implanted devices like Implanon or the IUD. Some women are minimally sexually active, or either prefer not to or cannot take any hormones and choose the barrier methods instead. Also, an important question to consider is what are the risks, side effects and benefits of each form of contraception.

The birth control pill is the most widely used contraception in the U.S. and is comprised of a daily pill consisting of  estrogen and progesterone or the progesterone only pill (often referred to as the “mini-pill”) which consists of only progesterone and is often used by those who cannot take estrogen and nursing moms. The combined pills work by preventing the body from ovulating. Without ovulation (releasing an egg from the ovary) there is no chance of a natural pregnancy for that cycle. The pills also work by changing the lining of the uterus, and altering the cervical mucous and the movement of the egg in the tube.(2) The pill is most effective if taken generally at the same time of day, although many women vary their timing and still have a low pregnancy rate. For the mini-pill however, it is very important to take the pill daily and at the same time of day, to reduce the chances of unintended pregnancies. In the package insert they always have instructions of what to do if you forget to take a pill, and these are good to read in advance so you have an understanding of what to do, just in case. Combined birth control pills and the mini-pill are 99.7% effective with perfect use and on average 92% effective with typical use.

Fortunately the newer birth control pills have low dosages of estrogen and progesterones with fewer side effects than the older ones, which make them widely used and well tolerated. There are about 40 different pills to choose from and there are many great brand name and generic pills on the market. There are always individual exceptions, but the main benefits of the pill are: extremely reliable contraception, shorter menstrual cycles with less bleeding, less menstrual cramps, less PMS symptoms, less perimenopausal symptoms, reduced acne, less unwanted hair growth, more predictable menstrual cycles, ability to skip periods for certain pill types, improved bone density, and lower risks of uterine and ovarian cancer.

The side effects of the combined pills can include: nausea, headaches, bloating, breast tenderness, breakthrough bleeding or spotting, and decreased sex drive. The risks of the combined pills include the risk of blood clots (pregnancy increases this risk too due to the hormones and this risk is highest in the first year of pill use), high blood pressure, and for women who smoke, increased risks of heart attack and stroke. We discourage all women from smoking while using the pill due to these risks, and absolutely do not prescribe the pill for women 35 and older who smoke. Those who should avoid combined birth control pills include those who have: a history of a current or prior blood clot (deep venous thrombosis), a blood clotting disorder, high blood pressure, a history of heart disease or stroke, severe migraines, who are 35 and older and smoke tobacco, have multiple cardiovascular risk factors (diabetes, smoking, high cholesterol) and have a current or past history of breast cancer.

After stopping the pill, typically fertility can return to normal after 3 months or less. Some women skip a pill or conceive on the cycle they stop birth control and that is okay and poses no increased risk to the baby. There are also women who had irregular menstrual cycles before they went on the pill, so once they stop, they return to irregular cycles which may then take longer to conceive. Many ask how long it is safe to be on the pill, and fortunately the pills nowadays are safe to use for years, as many women do. I’ve also been asked if there is a male pill on the market, and not as of yet, although researchers are studying this in the lab. Nowadays, one does not have to have a monthly menstrual cycle on the pill, and we’ll discuss this as well as other birth control methods in future newsletters.

Please keep the birth control questions coming and let us know what birth control methods you have had good and bad experiences with.

1, 2: Up To Date 2009.