Birth Control Options for Women - Oral Contraception

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Lybrel supplies a daily low dose of levonorgestrol and estradiol with no inactive pills. Because Lybrel contains only active pills, which are taken 365 days a year, it completely eliminates monthly menstrual periods. About 60% of women who take Lybrel completely stop menstrual periods by the end of the first year. Some women, however, experience occasional unscheduled bleeding or spotting during the first 3 - 6 months.

Progestin-Only Oral Contraceptives ("Mini-Pills")

Progestin-only pill brands include:

• Levonorgestrel (Plan B)
• Norethindrone (Micronor, Aygestin, Nor-QD)
• Norgestrel (Ovrette)

Progestin-only pills, which contain only progestins, are always sold in 28-day packs, and all the pills are active. An exception is Plan B, which is emergency contraception. [For more information, see Emergency Contraception section in this report.) Progestin-only pills, also called “mini-pills,” must be taken at precisely the same time each day to maintain effectiveness. If a woman deviates from her pill schedule by even 3 hours, she should call her doctor about using back-up contraception for the next 2 days.

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Progestin-only pill users experience even lighter periods than those taking combination pills. Some may not have periods at all. Because these pills do not contain estrogen, they may be a safer choice for women over age 35, smokers, and those who have other risk factors that contraindicate estrogen use.

Advantages of Oral Contraceptives

Oral contraceptives are the choice of most American women who use birth control, making them the most popular reversible contraceptives in the U.S. Oral contraceptives are among the most effective contraceptives. Failure rates are relatively low (9% with typical use) and are usually due to noncompliance.

Oral contraceptives also have the following advantages, which may vary depending on the type and brand used:

• Reduce menorrhagia (heavy menstrual bleeding) and, therefore, reduce the risk of anemia
• Reduce dysmenorrhea (severe menstrual pain)
• May help reduce symptoms of premenstrual syndrome. Yaz is specifically approved for treating premenstrual dysphoric disorder (premenstrual depression).
• Improve acne
• Improve symptoms of endometriosis.

• Reduce risks of ovarian cysts
• Possible protection against bone loss with estrogen-containing oral contraceptives
• Reduce risks of ovarian and endometrial (uterine) cancers with long-term use (more than 3 years)

Disadvantages of Oral Contraceptives

Common Side Effects. Many women have some side effects during the first 2 - 3 months of birth control use. These side effects usually subside. Estrogen and progesterone have different side effects, and women on the combined pill may have different effects from those on the progestin-only pill.

Common side effects of oral contraceptives include:

• Nausea and vomiting (can often be controlled by taking the pill during a meal or at bedtime)
• Headaches (in women with a history of migraines, they may worsen)
• Dizziness
• Breast tenderness and enlargement
• Irregular bleeding or bleeding between periods
• Weight gain

Newer formulations of combination pills that use low-dose estrogen, and newer progestins, may reduce and even lower the risk of many of these side effects, including weight gain.

Serious Side Effects. Symptoms of serious problems may include severe abdominal pain, chest pain, unusual headaches, visual disturbances, or severe pain or swelling in the legs. If you have any of these symptoms, contact your doctor immediately.

Potential Risks. Combination birth control pills can increase the risk of developing or worsening certain serious medical conditions. The risks depend in part on a woman’s medical history. You should discuss your health history with your doctor to determine if combination oral contraceptives are safe for you. This is especially important for women who are age 35 or older, smoke, or have a history of high blood pressure, high cholesterol or unhealthy blood lipid profile, diabetes, or migraine headaches.

Serious risks of birth control pills may include:

• Heart and Circulation Problems. Combination birth control pills contain estrogen, which can increase the risk for stroke, heart attack, and blood clots in some women. The risk is highest for women who smoke, are over 35, have diabetes or polycystic ovary syndrome (PCOS), or have a history of heart disease risk factors (such as high blood pressure or unhealthy cholesterol/lipid levels) or cardiac events. Women who have migraines may possibly be at increased risk for stroke and may need to consider progestin-only pills or other contraceptive methods in place of combination oral contraceptives. However, taking a birth control pills is generally safe for young, healthy women without other risk factors.
• Venous Thromboembolism. All combination estrogen/progestin birth control products carry an increased risk for blood clots in the veins (venous thromboembolism), which can lead to blood clots in the arteries of the leg or lung (pulmonary embolism). The risk is lower for oral contraceptives than for the birth control patch (Ortho Evra) or the ring (NuvaRing), which expose women to higher levels of estrogen than birth control pills. Women who smoke, who are obese, who have a personal or family history of blood clots, or who have heart disease risk factors may want to consider using alternatives to estrogen-containing contraceptives, such as progestin-only oral contraceptives ("mini-pills"), intrauterine devices, or barrier contraceptive methods.
• Diabetes. Women who have diabetes, and high blood pressure, vascular disease, kidney disease, or other diabetes-related health problems, should not take birth control pills.
• Cancer Risks. Several studies have reported an association between increased risk of cervical cancer and long-term (greater than 5 years) use of oral contraception. Although studies have been conflicting about whether estrogen in oral contraception increases the chances for breast cancer, the most recent research indicates that oral contraceptive use does not significantly increase breast cancer risk. Long-term use of birth control pills reduces the risk for ovarian and uterine cancers.
• Liver Problems. In rare cases, oral contraceptives have been associated with liver tumors, gallstones, or jaundice. Women with a history of liver disease, such as hepatitis, should consider other contraceptive options.
• Interactions with Other Medications. Certain types of medications can interact with and decrease the effectiveness of oral contraceptives. These medications include anticonvulsants, antibiotics, antifungals, and antiretrovirals. The herbal remedy St. John’s wort can also interfere with birth control pills’ effectiveness. Make sure your doctor is aware of any drugs, vitamins, or herbal supplements that you take.

Click the icon to see an image of cervical cancer.

Other Methods for Administering Combination Hormones (Patch and Ring)

The skin patch and vaginal ring are other hormonal contraceptive methods of administering the combination of progestin and estrogen. Failure rates with perfect use (0.1 - 0.6%) are similar to those of combined oral contraceptives.

Skin Patch. Ortho Evra is a birth control skin patch. It contains a progestin (norelgestromin) and estrogen. The patch is placed on the lower abdomen, buttocks, or upper body (but not on the breasts). Each patch is worn continuously for a week and reapplied on the same day of each week. After three weekly patches, the fourth week is patch-free, which allows menstruation. (The patch remains effective for 9 days, so being slightly late in changing it should not increase the risk for pregnancy.)

The Ortho patch exposes women to higher levels of estrogen than most birth control pills, and therefore increases the risk for blood clots in the veins (venous thromboembolism). Venous thromboembolism can cause blockage in lung arteries and other serious side effects. Older women (over age 40) and women with risk factors for blood clots (such as cigarette smoking or a family history of blood clots) may find other birth control products to be a safer choice. Discuss with your doctor whether the patch is appropriate for you.

Vaginal Ring. NuvaRing is a 2-inch flexible ring that contains both estrogen and progestin (etonogestrel). It is inserted into the vagina. Women can insert the ring by themselves once a month and take it out at the end of the third week to allow menstruation. It works well and may cause less irregular bleeding than oral contraceptives. Some women find it uncomfortable, and a few have reported vaginal irritation and discharge, but such problems rarely cause a woman to discontinue use. As with the patch, NuvaRing may put women who use it at higher risk for blood clots than oral contraceptives.

Review Date: 09/28/2010
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org).