Oral hormonal contraceptive pills have now become easily accessible over the counter and through several online retail stores without a prescription. This is GREAT news! However, you need to exercise great caution since they do have side effects and may not be the correct form of birth control for you!! Remember, online research can inform you of many things, but it is always best to consult a certified healthcare professional so you can take control of your body in a safe and educated manner!!
We have compiled a list of valuable tips so you can arm yourself with facts! As always, we are here to help seven days a week!
What are hormonal birth control pills?
Combined estrogen-progestin oral contraceptives (COCs), also known as birth control pills, provide reliable contraception as well as several non-contraceptive benefits. COCs contain an estrogen component and one of a dozen different progestins. For healthy, nonsmoking women, COCs may be continued until the age of menopause. The type of pill selection should include a patient’s experience with COCs, patient preferences, clinical characteristics, insurance coverage, and cost. Shared decision-making improves adherence to any contraceptive method.
How does the pill work?
The COCPs suppress ovulation by inhibiting gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and the mid-cycle LH surge. This effect is mediated by the synergistic action of the COC’s progestin and estrogen components.
How effective is the pill?
When taken correctly, COCs are a highly effective form of contraception. Although the perfect-use failure rate is 0.3 percent, the typical-use failure rate is more typically approximately 7 percent, due primarily to missed pills or failure to resume therapy after the pill-free interval.
Who should avoid taking the pill, and when?
We call these absolute contra-indications (Unacceptable risks: CDC – category 4 rating) because of the risk of blood clots, stroke, and death!
- Age ≥35 years and smoking ≥15 cigarettes per day
- Multiple risk factors for arterial cardiovascular disease (such as older age, smoking, diabetes, and hypertension)
- Hypertension (systolic ≥160 mmHg or diastolic ≥100 mmHg)
- Venous thromboembolism
- Known thrombogenic mutations- genetic mutations that can cause blood clots.
- Known ischemic heart disease
- History of stroke
- Complicated valvular heart disease (pulmonary hypertension, risk for atrial fibrillation, history of subacute bacterial endocarditis)
- Current breast cancer
- Severe (decompensated) cirrhosis
- Hepatocellular adenoma or malignant hepatoma
- Migraine with aura
- Diabetes mellitus of >20 years duration or with nephropathy, retinopathy, or neuropathy.
When can you take the pill but under close supervision?
We call these relative contra-indications (CDC- Category 3 rating).
OCPs may be considered individually if no other acceptable alternative is available.
- Age ≥35 years and smoking <15 cigarettes per day
- Hypertension (systolic 140 to 159 mmHg or diastolic 90 to 99 mmHg)
- Hypertension adequately controlled on medications
- Past breast cancer and no evidence of current disease for five years
- Current gallbladder disease
- Malabsorptive bariatric surgery
- Superficial venous thrombosis (acute or history)
- Inflammatory bowel disease with risk factors for venous thromboembolism (active or extensive disease, surgery, immobilization, corticosteroid use, vitamin deficiencies, or fluid depletion)
I have a family history of breast cancer and/or have the BRCA gene-positive status.
A family history of breast cancer or BRCA-positive status is NOT a contra-indication. COCPs can help reduce the risk of ovarian cancer and colon cancer in such patients.
There are so many birth control pills; how do I know where to start?
Again, a healthcare professional knowledgeable about the types, side effects, and dosing can guide you properly.
Below is a primer to help you get armed with facts!
Types of Combination Oral Contraceptive pills and dosing.
There are three types of OCPs based on the dose of Ethinyl Estradiol in the pill.
Ethinyl Estradiol (Estrogen types)
- Ultra low dose (<20mcg)
- Low dose (20 mcg)
- Standard dose (30-35mcg)
Progestin types
- High androgenicity but low blood clot risk. – Norethindrone/ Levonorgestrel.
- Low androgenicity but slightly increased clot risk – Norgestimate/ desogestrel.
- Anti-androgenic – Drospironone/ dienogest/ cyproterone acetate
The overall effect of all COCs, however, is antiandrogenic (suppress testosterone), regardless of the type of progestin used
- Oral Contraceptives (Mono-phasic)- these pills have the same dose of estrogen and progesterone throughout the cycle
First choice:
Low dose – for routine use, low side effects
(Ethinyl estradiol/ desogestrel or levonorgestrel)
Generic –Microgestin Fe 1/20 x 28/ Junel Fe 1/20 x 28 days/ Alesse/ Mircette
Second choice: (if history of breakthrough bleeding)
Standard dose (30-35 mcg) – Apri/ Microgestin – 1/30/ Junel 1/30
Ultra-low dose (10mcg) – Lo-loestrin.
This is usually preferred for patients unable to tolerate low-dose pills.
2) Oral contraceptives (Tri-phasic)
These pills have a different dose of estrogen and progesterone every week of the cycle. Below are some examples:
- Ortho-tricyclen Lo
- Camrese
- Tri-sprintec, regular or lo
Usually, these are not the first preference because of varying doses, but if you are already on one, there is no need to switch.
3) Oral contraceptives – 3 monthly – Endometriosis/ chronic pelvic pain
Skipping the placebo in Monophasic pills is the best option.
Or
- Quattro (4 months)
- Seasonique ( 30mcg EE).
- Jolessa (3 monthly packs – 30mcg EE).
- Lo-loestrin – skip placebo.
4) Transdermal – These are the same as the pill but come as a patch.
If you have increased breakthrough bleeding / are forgetful/ have a busy lifestyle, you can miss pills/ have small kids/ shift workers/ PMS, etc.
XULANE patch 1 q weekly x 3 weeks, then one week off.
5) Transvaginal – If increased breakthrough bleeding / forgetful/ lifestyle – missing pills/ have small kids/ shift workers/ PMS
Nuvaring – 1 ring every three weeks in, one week off.
THERE is a LOWER RISK OF THROMBOSIS WITH NUVA-RING -/ PATCH because it bypasses the liver, and there is constant absorption with stable serum levels. Avoids the peaks and troughs from oral absorption.
How should I start, and what should I watch out for?
- Start on the first Sunday after the period or Day 1 of the period. If start on Day 1 of period, will be protected in the same cycle. If Sunday start, use additional contraception in the first cycle. We do not recommend an early start or immediate start.
- Take bedtime after meals (Never on an empty stomach).
- Initial few days – nausea/ increased appetite – body develops quick tolerance.
- Very low dose ones like Loestrin/ lo loestrin – you may have irregular spotting throughout the cycle for the first three months. Just wait it out. No need to change the pill.
- Some of you may have decreased libido, hair fall, and weight loss.
I want to get pregnant; how long should I wait after stopping the pill?
COCPs do not cause infertility. There is no waiting time recommendation.
Always complete the pack when you stop the pills; otherwise, you can get irregular cycles.
I am 50 years old and on the pill. How do I know I am in menopause?
- If you need to check for menopause, stop OCPs for at least six weeks and then get blood work done with your provider to check for FSH and Estradiol levels.
I am on the pill. Can I still get STDs?
No, OCPs do not offer protection against STDs.
I have severe PMS. Will the oral pill help?
NO! That’s a myth!!!
Check out our PMS blog to learn more!
Do pills help with Acne?
Yes, if the acne is from high testosterone
Prefer Low androgenic and monophasic types.
Example: Junel 1/20 ( Desogestrel containing).
How do I know if any other drugs that I am taking can affect the pill?
It’s hard to know! That’s why you should consult your healthcare provider. Still, we have compiled some interactions to watch for:
DECREASED EFFICACY (High chance of failure)
The efficacy of COCPs may be decreased by any drug that increases liver microsomal enzyme activity.
Anticonvulsants :
Anticonvulsants that reduce the efficacy:
Phenytoin, carbamezapine, barbiturates, primidone, topiramate, felbamate, or oxcarbazepine.
If using OCPs with above anticonvulsants:
- Use a standard dose OCP with a minimum of 30 mcg of ethinyl estradiol + progestin with a longer half-life (drospirenone, desogestrel, levonorgestrel).
- Skip placebo or preparation with a four-day hormone-free interval.
Anticonvulsants that do not appear to reduce contraceptive efficacy:
Gabapentin, levetiracetam, valproate, zonisamide, and tiagabine.
Lamotigrine and OCP’s
COCs can result in a decrease in plasma lamotrigine concentrations by 45 to 60 percent. This can increase the risk of seizure.
- Consult with neurology to adjust dosing.
- To avoid fluctuating lamotrigine levels, continuous dosing of the COC rather than cyclic is recommended.
Antibiotics
Rifampin is the only antibiotic proven to decrease serum ethinyl estradiol and progestin levels in women taking COCs (due to enzyme-inducing effects).
Antiretrovirals – Refer to current texts.
St. John’s wort –May increase the risk of ovulation.
Useful things to remember:
- If you have irregular cycles or bleeding between cycles or after sex, it’s essential that you see a GYN for a complete evaluation, including an ultrasound and blood work!
- If you are obese or overweight patients – please get blood work to rule out pre-existing elevated liver enzymes.
- NEVER do an immediate start.
- If you miss one pill, take two the next day and finish the pack. If you miss two, finish the pack but use additional protection in that cycle.
- With many pills, your periods may get lighter and may even go away, but please do a pregnancy test to confirm.
- Try and take the pills at the same time every day – set an alarm on your phone.
- Pills do not cause weight gain by themselves, but if your body is not a good estrogen metabolizer, you may experience bloating breast tenderness, and water retention.
Overall, it’s great to have easy access to hormonal birth control, but please remember to be well-informed!
Be safe, be strong, and be prepared!
Dr. Adeeti Gupta and the lovely team at Walk In GYN Care