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Hormonal Birth Control (HBC)
When it comes to questions, hormonal birth control is another of VP's most frequent topics.
What is hormonal birth control (HBC), and how does it work?
Hormonal birth control is any method of birth control that works by putting hormones into the body. Some examples would be pills, the patch (Ortho Evra), and the ring (Nuva Ring). There are two types of hormonal birth control: combined methods, which contain both synthetic estrogen and synthetic progesterone (progestin) and progestin-only methods (Depo, the Mirena IUD, and the minipill / progestin-only pill are examples of progestin-only methods). Doctors can help to determine which method is the best for a particular individual. Combined methods are slightly more effective than their progestin-only counterparts, but the difference is small, and some people can't take estrogen for one reason or another. Those looking to begin HBC should talk to their doctors about which method is best for them.
With most methods of combined birth control, the user has three weeks of active pills (or three weeks on the ring or patch) and one week of inactive pills. Active pills contain the hormones that prevent pregancy. The inactive pills are sugar pills, they're just there to keep the user in the habit of taking a pill every day. It is not necessary to actually take the placebo pills since they are just reminders (on the patch and the ring, the user just goes without a patch or ring for a week). This inactive week will induce a period (that will be explained in more detail later).
In order to be fully protected, the user must take at least 21 days of active pills and have no more than 7 hormone-free, or placebo days. Taking less than 21 consecutive active pills or extending the off week to more than seven days, either by stopping the HBC early or by starting a new pack late, can cause normal ovulatory function to resume, which can lead to pregnancy.
In general, combined methods of BC are over 99% effective if taken perfectly, and around 95% effective with “typical use.” Combined methods stop ovulation, thicken the cervical mucus, and thin the uterine lining. Progestin-only methods thicken the cervical mucus and thin the uterine lining, but most women continue to ovulate while using these methods. This will be discussed in more detail later on.
For more information on how HBC works, check out this helpful comment from geminigirl:
"[Hormonal birth control] affects the production of certain hormones in your body (FSH and LH.) By doing that it does three things-it prevents ovulation-no egg released means no egg to fertilize, it thins the lining of your uterus, making it an inhospitable places for a fertilized egg to try and implant (and thus for most people, making periods lighter and shorter,) and it thickens the mucous at your cervix, making it much harder for sperm to get through and try to fertilize an egg."
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What are the different types of HBC?
There are many, many different brands of birth control pills. They differ in hormone levels/amounts, types of hormones, and sequence of pills. Another way pills differ is monphasic or triphasic dosage. Monophasic means that all pills in the 3 active weeks (the pills that contain hormones) have the same amount of hormones in them. Triphasic pills have a different level of hormone for each active week. Triphasic pills are meant to mimic a natural cycle, but some women react badly to the constant change in hormone level. It is also more difficult to skip periods effectively using a triphasic pill. Because monphasic pills contain a constant level of hormones in all active pills, they are better-suited to skipping periods. The Nuvaring and Evra patch are each monophasic methods of BC. Which method is right for you will vary from person to person – the best thing to do is to talk to a doctor about what you're looking for, and then give one a shot and see how it goes! Remember, many women try multiple types of HBC before finding one suited to their individual needs; this is perfectly normal.
For a quick-and-easy comparison of some of the more common oral contraceptive formulations, you may wish to check this chart.
In addition, because there are so many different types of HBC, some may have different instructions in different circumstances than do others. This article offers general guidelines, but the best source of information about your particular type of HBC is often the patient information pamphlet related to that particular type.
Pills
Sometimes just referred to as "the Pill," oral contraceptive pills actually come in a variety of different forms. One pill is taken each day at approximately the same time. According to the International Planned Parenthood Federation, oral contraceptive pills are generally available in all regions of the world, though both brand names and specific availability may vary from nation to nation.
Combined Pills
Generally, one active pill is taken each day for 21 days. With combined pills, perfect use means taking one pill at the same time every day.
Monophasic Pills
With monophasic pills, each active pill has the same amount of hormones as the active pill before it and the active pill after it. Some examples of monophasic pills, as well as links (some in PDF format) to more information:
Examples:
- Alesse (PDF)
- Lybrel -- With Lybrel, you take an active pill every day, 365 days per year. Though it's intended to eliminate periods completely, studies show that some users experience breakthrough bleeding on Lybrel.
- Ovcon (PDF)
- Seasonale -- Seasonale is a moderate-dose monophasic pill set up with 13 weeks of active pills and one week of placebos, or inactive pills. Theoretically, a Seasonale user would only get 4 periods per year, though research and anecdotal experience both indicate that spotting or breakthrough bleeding is very common on Seasonale.
- Yasmin (PDF)
Triphasic Pills
With triphasic pills, each week of active pills has a different level of hormones.
Examples:
- Estrostep (PDF)
- Ortho Tri-Cyclen
- Ortho Tri-Cyclen Lo (PDF)
Progestin-Only Pills
Also called POPs or mini-pills, these pills contain no estrogen, only synthetic progesterone. One active pill must be taken at the exact same time each day in order for the pills to be fully effective. It is also worth noting that some sources cite perfect use effectiveness for POPs as slightly lower than perfect use for combined pills.
Examples:
- Ortho Micronor (PDF)
- Femulen
- Cerazette (Cerazette is unique among POPs in that a pill is not missed unless it is taken 12 or more hours late; its perfect use effectiveness has also been shown to be comparable to that of combined hormonal methods.)
Non-Pill Methods of Hormonal Birth Control
Patch--The Ortho Evra patch is a patch worn on the skin that releases hormones into the body. It is as effective as the pill, but only needs to be changed once a week (rather than taking a pill every day.) It is a monophasic method. Often called Evra outside of the U.S., the patch is widely available throughout North America, South America and Europe; it is available on a more limited basis in parts of Africa, Asia, and Oceania, according to the IPPF.
Ring--The Nuva Ring (PDF) is a small, flexible ring worn inside the vagina. It is generally removed every 3 weeks to induce a period, though according to this information from the Nuva Ring website, there are actually sufficient hormone concentrations to allow for 4 weeks (28 days) of use from a single ring. The ring is monophasic, as effective as the pill, and easier to remember because it only requires user action once every three weeks instead of daily. Aside from one's "period week," the ring can be taken out for up to three hours at a time (do note: there is controversy regarding how often the ring can be taken out - whether the three hours is daily, weekly, or monthly. Discuss this with your doctor or pharmacist prior to removing your ring at any time other than your period week). The Nuva Ring is available in the U.S., Canada, and parts of Europe, as well as on a more limited basis throughout the rest of the world. In addition, according to Info for Health's Population Reports, a second contraceptive ring called Nestorone, which would be effective for 12 months at a time, is currently being developed for use in developing countries.
Shot--Sometimes simply called "Depo," the Depo Provera shot is a dose of progestin injected into the arm or tush every 11-13 weeks (about three months). Depo is very effective and only needs to be addressed every three months, but the downside is that if the user does have undesirable side effects or problems, the hormones remain active in the body for the full three months regardless. Like oral contraceptive pills, the progestin-only shot is generally available worldwide, though specific availablity and brand names vary based on location.
Implant--Implants are small, thin rods made of plastic or silicone; the implant is inserted into the upper arm, just below the skin. Implants work by releasing small amounts of progestin, which thickens the cervical fluid and inhibits ovulation. Hormonal implants are generally effective for 3 to 5 years, after which they must be replaced. Jadelle is available in a few countries in Africa, Latina America, and Scandanavia and Great Britain, while Norplant and Implanon are available in many countries of the world. In July 2006, the FDA aproved Implanon for use in the U.S. Check here to see if there's an Implanon trained clinician near you.
IUD--An IUD is an intra-uterine device-a T-shaped object that is inserted into the uterus (in a non-surgical procedure)-to prevent pregnancy. IUDs are not always hormonal, but the Mirena is. Mirena releases a tiny amount of progestin into the uterus, which thins the uterine lining and thickens the cervical mucus. The presence of the IUD in the uterus also prevents pregnancy, as explained in this comment by ncsu_lady:
"[T]he Mirena works by making the uterine environment inhospitable to sperm and egg and also sweeps any ovulated egg out rapidly to prevent ever meeting with sperm. This is the defined definition of an IUD. It is suspected that the levels of progestin actually helps to 1. prevent ovulation and 2. thins the uterine lining to help women have light to nonexistent periods."
The Mirena is 99.9% effective and effective for 5 years. A Mirena is theoretically easier to insert in a woman who has been pregnant (because it's more likely to fit, and less likely to expel), but it is possible and safe for women who have never been pregnant to get an IUD. According to the IPPF, the Mirena is widely available throughout Europe (under the brand name Levanova in Scandanavia), North America, and South America; it is less widely available elsewhere in the world.
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What is low dose HBC? Is it safer than higher dose HBC?
According to Family Health International, in the 1960s and 1970s, many women who used HBC took doses containing from 50 micrograms (mcg) of estrogen; some formulations contained as much as 150mcg of ethinyl estradiol. These same formulations contained up to 10mg of progestin.
Today, as Contraception Online notes, 98% of HBC prescriptions are written for low dose varieties, those containing 35mcg or less of ethinyl estradiol and low doses of progestin. In terms of safety, the site says:
"It is believed that lowering the dose has helped to decrease the occurrence of serious side effects first seen with higher-dose pills. These low-dose pills have also helped decrease the occurrence of minor, but annoying, side effects, such as nausea and bloating."
For a more detailed explanation on the relative risk of circulatory system diseases with low dose HBC, check out what The Johns Hopkins School of Public Health has to say about it.
Some health care providers may refer only to methods containing 20mcg or less of estrogen as "low dose." However, the important fact to consider is that all of these formulations are effective as contraception. If you're concerned about the formulation of your specific brand of HBC, you may wish to contact a pharmacist or other health care provider or to check this section of the Vulvapedia for instructions on how to search for your pill information.
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How do I get me some of that HBC?
In the US and most countries, hormonal birth control is available by prescription only. One can get it from a gynecologist, primary care doctor, health department or college health center, or from Planned Parenthood or another local clinic or health department. Cost will vary, but if one has no money or insurance, it's best to talk to Planned Parenthood or, in an area where PP is unavailable, other low-cost health clinic. Often, they allow payment on a sliding scale according to the patient's income level. HBC is sometimes covered by insurance. Doctors are given free samples of HBC by pharmaceutical companies and will often pass those samples along to patients if those patients ask. If one must pay out of pocket and at full price, HBC may cost up to $60 US per month.
To get hormonal birth control, a woman usually needs an exam, though some Planned Parenthood locations actually offer a program called HOPE, which stands for hormonal options without pelvic exam. If you're interested, you need to find out whether a health care provider near you offers this or a similar option.
If your health care provider requires an exam, this will generally involve a pelvic exam, a breast exam, and normal doctor stuff like getting weight, height, and blood pressure checked. The doctor should also ask questions about medical history and family medical history, and the patient should have an opportunity to ask questions and raise concerns.
Because hormonal birth control is a prescription medication, it is important that you take only those pills that were prescribed to you. VP does not advocate sharing prescriptions.
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How should I store my HBC?
The U.S. National Library of Medicine recommends the following storage conditions for combined oral contraceptives, progestin-only oral contraceptives, the patch, and the ring:
"Keep this medication in the packet it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication."Though pharmacists will often refrigerate Nuva Ring to maximize its shelf life, its prescribing information states that it can be stored at room temperature for up to 4 months.
Managing Contraception further mentions to store HBC away from direct sunlight and specifies room temperature as 20-25 degrees Celsius (68-77 degrees Farenheit), though you may also wish to check the information for your specific brand.
Patient storage information for Depo Provera, hormonal IUDs, or hormonal implants is generally not necessary as the active hormones--and in some cases, even the physical device--remain in the body.
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OK, I've got some HBC now. How do I start taking it?
There are three basic ways to begin taking hormonal birth control pills, patches, or rings. One is not inherently better than another: the "right" method for an individual depends largely on the priorities of that user, and upon her doctor's direction.
Day One Start--Start on the first day of a menstrual period. As long as the first pill is an active pill (which is the case throughout much of the world), you will be protected immediately from pregnancy. One advantage of this method is that it provides a sign -- your period -- that you're not pregnant so protection can begin immediately. Some have also reported that this method reduces breakthrough bleeding; some, however, have reported more of it.
Sunday Start--With this method, start on the first Sunday after a menstrual period begins. Users of this method are protected from pregnancy after they have correctly taken 7 active pills/days of hormones correctly. This method provides an "easy" calendar day -- Sunday, the beginning of the week -- in which to start. Some people choose this method in the hope that their withdrawal bleeds won't start on the weekends.
Quick Start--With this method, start on any chosen day, regardless of menstrual cycle. Users of this method are protected from pregnancy after they have correctly taken 7 active pills/days of hormones correctly. This allows you the convenience of starting any time you want, without having to wait for your period. It may or may not result in more breakthrough bleeding during the first cycle.
The recommendation that a backup method needs to be used for only 7 days (or not at all, depending on the start method) are provided by the World Health Organization. Some doctors--as well as some websites like Gannett Health Services--recommend using a backup method for the first month of pills in order to keep you protected while you're getting into the habit of taking your pills. While this is excellent advice to maximize pregnancy protection, HBC itself becomes fully effective after 7 days of correct use.
The full prescribing information for Depo Provera (the shot), however, does come with more specific instructions:
"The recommended dose is 150 mg of DEPO-PROVERA CI every 3 months (13 weeks) administered by deep, IM injection in the gluteal or deltoid muscle. To ensure the patient is not pregnant at the time of the first injection, the first injection MUST be given ONLY during the first 5 days of a normal menstrual period; ONLY within the first 5-days postpartum if not breast-feeding; and if exclusively breast-feeding, ONLY at the sixth postpartum week. If the time interval between injections is greater than 13 weeks, the physician should determine that the patient is not pregnant before administering the drug. The efficacy of DEPO-PROVERA CI depends on adherence to the dosage schedule of administration."While it may be reasonable to infer that, if begun at any other time, the Depo Provera shot will achieve full efficacy after 7 days, and while several health care professionals do advise this, the prescribing information mentions nothing about this. If you've received or will receive a first Depo injection at a time other than the ones specified, you may wish to discuss with your health care provider when the shot will reach full efficacy.
| Region-Specific Note:
As suggested in this LJ post, pills in Australia are sometimes packaged in such a way where the user does not start with an active pill but rather with a placebo. According to this PDF factsheet (PDF) from Australia's Sexual Health and Family Planning A.C.T., the basic guidelines that should be followed are these: "When starting the pill it will be effective straight away if the hormone pills are started on the first day of your period. If you start with a sugar pill or later in the month, it will be effective after you have taken 7 hormone pills in a row." In this case, a user may have to take up to 14 total pills before she's taken 7 active pills and thus is protected from pregnancy. If this situation applies to you, you may wish to keep careful track of when you've taken 7 active pills to know exactly how soon you're protected. |
What's the difference between typical use and perfect use?
According to Planned Parenthood, perfect use refers to "use that is consistent and always correct."
As applied to birth control pills, this means taking each active pill at the same time each day. For any HBC, it also means checking for any substances that could interfere with the hormones and using a reliable backup method as necessary. All hormonal contraceptives listed here have a perfect use success rate of at least 99.7% Guttmacher Institute.
The term typical use refers to how well a method works in the real world. It represents how correctly the "average" woman uses that method, and it includes women who miss pills, who take pills late, who take pills out of order (generally for triphasic methods), or who do not always use reliable backup protection when necessary. According to the Guttmacher Institute, typical use rates range from 92-97%.
It is important to remember that typical use represents an "average" range. The fewer mistakes a user makes with her birth control method, the closer she can come to being protected at the "perfect use" rate.
Travel, Daylight Savings, and/or LIFE is happening, and my pill time may change. How do I do it?
Oral contraceptive pills are at their most effective if taken at the same time each day. Taking pills in this manner helps supply the body with a constant level of hormones. This is considered "perfect use." That said, it's not always practical or possible to plan your life around your pill-taking, and there are times when a time change might need to happen.
For those taking combined oral contraceptives, perhaps the best method to change pill time is to wait until after the placebo week and the beginning of a new pack. If you plan to take your pill earlier, you can still do this on your normal day; however, if you plan to take your pill at a later time, we recommend doing so one day earlier so that you don't extend your hormone-free week beyond 7 days. (For those using the patch or the ring, the same advice applies. You can change your time earlier, but we don't recommend extending your hormone-free week as this could compromise protection.) When this method is not convenient for COC users, perhaps it is best to consider this advice from Managing Contraception:
It is not a big deal if you take an occasional pill several hours late. Actually, pills are quite forgiving of minor variations (hours) in the schedule of taking them.
This means that if you have otherwise been taking your pills at the same time, changing the time for one pill should not measurably compromise its effectiveness. Thus, if you're traveling across time zones, you can change your time once so that when you arrive at your destination, your pill-taking time is still one that's manageable for you. For people having concerns about Daylight Savings Time changes, you can continue to take your pill at the same clock time since the one-time one hour difference is not likely to alter the pill's overall effectiveness.
However, if your use has been somewhat erratic, changing the time at which you take your pill may place your particular effectiveness into the "typical use" rate of 92-95%. Moreover, if you are 12 or more hours "late" taking any one pill, you should follow the directions in your pill pamphlet regarding missed pills.
For those taking progestin-only pills, it is very important that you take your pills at the exact same time each day, as POPs are more sensitive to time changes than are combined contraceptives. As Planned Parenthood mentions:
Taking the progestin-only pill at the same time each day is essential — if you take it more than three hours past the regular time, you need to use a back up method of birth control for 48 hours after taking the late pill.
This should be taken into consideration when deciding if or when to change the time at which you take your POP.
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What are the side effects of HBC?
First off, the side effects an individual experiences depends widely on that person's body chemistry. It's generally impossible to predict how any one person will respond to a specific brand of hormonal contraception.
There are, however, several side effects common to all kinds of HBC, as well as less common but more serious effects.
Common Side Effects
- Menstrual Changes--Periods can be shorter or longer on HBC, and you may bleed more regularly, or experience some random, irregular bleeding, especially at first. In addition, according to the Feminist Women's Health Center, irregular bleeding is an especially common side effect associated with progestin-only methods.
- Breakthrough Bleeding / Spotting--It's common while adjusting to HBC; missing pills, even if you make them up later, can increase the chances of spotting. If it continues past the 3 month mark or is intolerable, talk to your doctor and see what s/he recommends. While irregular bleeding can sometimes be symptomatic of a medical condition that requires treatment, it's also something that, even after the adjustment period, can happen on HBC for no discernible reason.
- Lack of Babies--a very positive side effect experienced by most women on hormonal birth control!
- Headaches
- Appetite Changes--This can include nausea and, occasionally, vomiting. It can also include increased appetite.
- Breast Growth or Tenderness
- Libido Changes
- Mood Changes
- Vaginal Fluid Changes--While some women note that it's more difficult for them to produce arousal fluid during sex, others experience leukorrhea, an increase in healthy, white vaginal discharge.
- Yeast Infections--As we note here, this pertains to HBC containing estrogen. The increased levels of estrogen in the body can change the vaginal environment, triggering yeast infections for some.
- Acne--Although, according to Contraception Online, "Numerous studies have reported acne improvement with various OC formulations," many HBC patient information pamphlets do list it as a possible side effect. For some, the hormonal changes--sometimes due to adjustment--can increase acne instead of decrease it.
In addition, just as many women not on hormonal birth control can experience symptoms like mid-cycle cramping, spotting after intercourse, or other things that make you go "hmm, I wonder what's going on there", many women on hormonal birth control can experience the same things. As always, if it's extreme in duration, discomfort, or otherwise worrying you, seek medical attention for evaluation and reassurance.
It's also important to keep in mind that the absence or presence of side effects does not affect your level of protection -- as long as you are using HBC correctly, you can consider yourself protected, whether or not you experience (or don't experience) any of the side effects listed above.
Rare but Serious Side Effects
These effects happen to only a very small percentage of HBC users, but they do happen.
- Blood Clots
- Stroke or Heart Attack
- Death--Very very extremely rare!
What about weight gain as a side effect?
Basically, there's no direct link between hormonal birth control and weight gain. Some types of HBC can more readily lead to weight gain in individuals -- see our earlier disclaimer about side effects -- and some types of HBC can lead to water retention and/or increased appetite. However, it's also important to consider that many women begin taking HBC in their later teens and early twenties, during which time they may gain weight and experience changes in their body shape regardless of whether or not they take HBC.
If you feel that a particular weight gain is directly caused by HBC, you might consider talking to your doctor.
How long do side effects last?
It varies widely, but often most of the side effects will be over quickly. What you feel on day one isn't necessarily what you're going to feel on day 3, or 10, or 21. There is an adjustment period when starting hormonal birth control of 1-3 months. Often, if you can wait out the side effects, they will subside after that amount of time. If they do not go away after 3 months, or they are unbearable/not something you want to live with, feel free to call your doctor and tell him/her that! S/he will be able to talk to you about the situation, and switch your prescription, if needed. Sometimes finding the right hormonal birth control for you takes time, trial, and error. Hang in there!
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What can I do about my side effects?
If you've waited out the 3 cycle adjustment period, and one particular side effect just isn't going away, you may want to consider switching to a new formulation of HBC. This page from the University of Michigan suggests that side effects such as bloating, headaches, nausea, mastalgia, leukorrhea, hypertension, melasma, and telangiectasia are often related to estrogen levels. These side effects may be minimized by switching to a formulation with a lower estrogen content. Similarly, side effects such as mood swings, mastalgia related to the menstrual cycle, depression, fatigue, decreased libido, and weight gain may be related to the strength or type of progestin in the formulation. This page suggests that switching to an HBC type with a lower progestin potency may lessen these side effects.
The Cochrane Review also notes that pill formulations containing 20mcg of ethinyl estradiol may have increased rates of breakthrough bleeding compared to formulations with higher estrogen contents, at least in the first few cycles. However, at least one study has found that by the third cycle, breakthrough bleeding levels tend to even out. Additionally, Contraception Online notes that several factors -- such as missed pills and/or use of other medications -- limit the conclusions that can be drawn from these types of studies, at least the ones that have been conducted to date.
It's also important to remember that when it comes to HBC and side effects, there really are no guarantees. While switching to another type of HBC may lessen a particular side effect, this doesn't hold true for everyone, and it's possible that switching to a new brand may produce a new side effect for you. If you're considering switching, you may wish to weigh the pros and cons carefully and to discuss your concerns with your health care provider.
Are periods, or "withdrawal bleeding," normal while taking HBC?
So, you've got three weeks on the hormones, and one week off. During this one week off, your period will arrive. (This can happen on the first day of the “off” week, or the last, or anywhere in between - any time during your off week is considered normal. Don't panic if your period doesn't come right away! It does not necessarily mean that your pill is not working correctly or that you are pregnant.) Periods on hormonal birth control aren't the same as “real” periods, because you don't have a natural menstrual cycle when you're on hormones. Periods on hormonal birth control are actually withdrawal bleeding caused by the lack of hormones in your system. It's safe and normal, it just isn't a “real” period caused by your natural menstrual cycle. Sometimes your period on HBC may be very light or nonexistent – this isn't necessarily cause for worry, because the hormones thin your uterine lining and sometimes there just isn't much of anything to shed. So why have periods on hormonal BC? For some women, it's comforting. It makes them feel more natural and it's reassuring to bleed and know they aren't pregnant.
Periods on hormonal birth control can be wacky compared to what you're used to, especially when you first start. So don't be alarmed if your period doesn't come until late in the placebo week. For some women, withdrawal bleeding starts right away, and for others it takes most or all of the placebo week. Either way, it's fine. It's even fairly normal to miss a period now and then on hormonal BC, or to have very light, spotty periods. If this happens to you and you're concerned about pregnancy, take a test - but remember, HBC taken correctly is extremely effective, so odds are good that you will be fine!
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What happens if I experience early periods while on the pill?
Does having my period during active pills mean that my pill isn't working? Do I need to switch pills? Will switching to a different pill help?
Rest assured, as long as you've been taking your pills correctly, the presence or absence of side effects does not mean that your pill is not working. If this (or any!) particular side effect is unbearable -- or if it extends beyond your adjustment period -- consider discussing this matter with your doctor. S/he may conduct tests to rule out other medical issues, or may recommend switching to a different pill to minimize these effects.
Experiencing an early period on HBC does not mean that you should stop taking your active pills and switch to the placebos -- doing so will affect your level of protection. If you experience an early period, you should continue to take your pills as usual.
For more information, browse through this post in VP on LJ.
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Can I skip periods on hormonal birth control?
It is possible to skip periods or suppress cycles on hormonal birth control, whether this is your first pack or whether you've been on HBC awhile. Health care providers generally consider this safe--though many recommend allowing yourself a withdrawal bleed every 3 months--but for best results, it's important to consider what kind of HBC you're taking.
- Progestin-only Pills (POPs)
- If you're on a progestin-only pill, it's important to remember that you take one active pill at the same time each day. You don't have any placebo pills to help you "skip."
- Monophasic Pills & Non-Pill Methods
- If you're taking a monophasic combined contraceptive (again, these are the ones with all the same color/size/shape active pills), you can skip your period by simply skipping the “off” or inactive week and going straight from the end of one active pill/patch/ring cycle to the next without a break.
- If you're taking a monophasic pill with 24 active pills and 4 placebo pills -- brand names currently include Yaz and Loestrin24 Fe -- you can still skip your period by skipping the inactive days and proceeding directly to your next pack of active pills. As with traditional monophasic pills, it may or may not work for you. What's important to remember with this type of pill is that since your active pills don't come in multiples of 7, the day of the week on which you start a new pack will change from one pack to the next.
- If you use a brand with some "therapeutic" placebo pills containing small amounts of estrogen -- such as Mircette -- treat these pills as you would hormone-free inactive pills. That is, skip all 7 placebo pills and proceed directly to the active pills in your next pack.
- For those using a non-pill method like Ortho Evra or Nuva Ring, simply skip your off week and apply a new patch or insert a new ring. According to the patient information, Nuva Ring users may also leave their ring in an additional week (28 days total) to delay periods by a week. This will not compromise pregnancy protection.
- Triphasic Pills
- If you're taking a triphasic pill, you may have to plan ahead to skip your period. There are a few ways of doing this - one method involves taking one month's pills "forward" (from lowest hormone dose to greatest hormone dose) and the second month's pills "backward" (from greatest hormone dose to lowest hormone dose) to avoid the steep drop in hormones that would trigger a period; with this method, the placebo pills should be skipped. Another method is to take the first week of 2 packs (pack A and pack B) of pills, followed by the week 2 pills for pack A and pack B, followed by week 3 pills for pack A and pack B. Regardless of which method you choose, it may be more difficult to skip one's period on triphasic pills than it would be on monophasic pills.
A couple of notes about skipping periods: It can be great when it works, but it doesn't work for every woman, and won't work as well if you do it every month. Sometimes, when women skip periods, they experience breakthrough bleeding or other "period-like" symptoms, including cramps, breast tenderness, or other changes that can be associated with PMS. In addition, it's generally recommended that all women on hormonal birth control who skip periods allow themselves at least one period every three months to minimize the chances that you experience breakthrough bleeding or spotting.
For more detailed information on different methods to skip your period, check out The Well-Timed Period's "Skip Period Regimens" post.
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Am I still protected from pregnancy during my hormone-free week?
Yes, you remain protected from pregnancy as long as you have correctly taken at least 21 active pills/days of hormones and no more than 7 placebos/days without hormones, and you haven't taken any antibiotics or other prescribed medications which can interfere with birth control.
Women taking HBC are protected during the placebo week because 21 days of HBC essentially puts the ovaries to sleep. During the hormone-free week, the ovaries do wake up and begin the normal pre-ovulatory process, but seven days is not long enough for the follicles to fully develop. Before ovulation can occur, the user has resumed taking active pills again.
This is why it's important to take pills correctly since missed ones can start to stimulate the follicular/ovulatory process. It's also why it's especially important not to extend the off week to more than seven days, either by stopping the HBC early or by starting the new pack late: because normal ovulatory function does begin to resume in the off week, and can continue to the point of ovulation if HBC is not resumed after seven days.
For more information, you may want to consult this source from Population Reports.
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What do I do if I am late with my hormonal birth control? What if I miss a dose?
Consult the information that came with your pill or other method; it can give you instructions specific to your type of HBC. Always save this information since you never know when you might need it!
Alternatively, you can Google for your pill information (often pamphlets are available online). If you'd like more specific resources, you can check out the LJ community pillpamphlets, an online collection of HBC patient insert information.
Some Sites' General Recommendations
This is not intended to be a substitute for consulting either the instructions specific to your brand or a health care professional for advice on how to proceed. If you are uncertain about what to do in the event of a missed dose or doses, your best bet is to check one of the above sources for instructions.
According to Population Reports, which is published by The Johns Hopkins School of Public Health and which cites the findings of a study conducted by the World Health Organization, states, "If pills are missed, the risk of pregnancy depends on how many pills were missed and when the pills were missed". While it also suggests that there are points during a cycle in which a user can miss multiple doses without significantly raising her risk for pregnancy, it should be noted that most health care professionals and most HBC patient instructions recommend more cautious approaches.
Combined Hormonal Contraceptives
For combined hormonal methods, a dose is considered "missed" if it is taken 12 or more hours late. Many pill instructions, as well as the Cowell Student Health Center of UC Davis, suggest this:
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What can you do if you miss taking your combined oral contraceptive pills? Follow the instructions for the scenario that best fits you. If you missed 1 active (hormonal) pill or if you started a pack 1 day late:
If you missed 2 or more active (hormonal) pills or if you started a pack 2 or more days late:
If you missed any inactive (non-hormonal) pills:
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Some pill brands, however, as well as some sites like Brown University's Health Services advise backup protection after even one missed pill. It is because of this variation that VP recommends that consulting either your pill instructions or a health care professional for advice specific to your brand and situation.
Progestin-Only Pills
A progestin-only pill is considered missed if it is taken 3 or more hours late. If you miss one or more doses of a POP, the McKinley Health Center at the University of Illinois recommends this course of action:
| WHAT IF PILLS ARE MISSED OR TAKEN LATE?
If you are three or more hours late or you miss one POPs; take the missed pill as soon as you remember that you missed it; THEN go back to taking your POPs at your regular time. Be sure to use a backup method (such as condoms and/or spermicide) every time you have sex for the next 48 hours. If you miss two or more POP's in a row; restart your POP's right away and take two pills a day for two days. Be sure to use a backup method for the next seven days. If you miss two POP’s in a row there is an increased risk of pregnancy. Immediately start using a back-up method. Restart your POP’s right away and take two pills a day for two days. If your period does not begin in 4-6 weeks, talk with your clinician for evaluation and pregnancy testing. |
Again, these are general guidelines only and are not meant as a substitute for your own pill's instructions or the advice of a medical professional.
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What if I'm early instead of late?
The same principle still applies. You did not lower the pill's effectiveness by taking this one sooner, but since there will be more than 24 hours between this pill and the next one, the next pill may be considered late.
If you took your pill less than 12 hours early (3 hours for a POP), you can remember this advice from Managing Contraception: "pills are quite forgiving of minor variations (hours) in the schedule of taking them." Since this doesn't constitute a missed pill, a one-time variation like this shouldn't measurably affect your contraceptive protection.
If you took your pill more than 12 hours early (3 hours for a POP), you may want to consider changing to this earlier time for the rest of your pack so your next pill will not be late enough to qualify as "missed".
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What do I do if I lose a dose entirely?
Hey, accidents happen. And those birth control pills? Tiny little suckers. It's all too easy for one to fall in the toilet, down the drain, or into the deep, dark, recesses of Behind the Couch. The problem is, many instructions for what to do in the event of missed pills assume that the missed pill will be made up at some point during the month. In cases where the pill is "gone forever," however, this simply isn't possible. In these cases, some advance planning and/or quicker action can be necessary.
In order to retain the uncompromised contraceptive effectiveness of HBC, the important rule to remember is this: To remain protected, you need to have AT LEAST 21 days of active hormones followed by NO MORE THAN 7 hormone free days.
One option is to keep a spare pack of HBC pills (or spare patch or spare ring) on hand for use in "lost pill" or other unexpected situations. If you use this method, you can simply take an equivalent pill from the next pack. For monophasic pills, this means you can take any active pill from the next pack since each active pill contains the same dose of hormones. For triphasic pill users, this means you should take a pill of the same strength--in other words, the same color--as the one you lost. After this, you can continue your HBC schedule as normal.
It's important to keep in mind that, at least for those in some countries, if you're trying to obtain a spare--or "extra"--pack of HBC before you're regularly scheduled to receive it next, your insurance or other discount payment program (if applicable) may not cover their usual portion of the cost, and you may need to pay full price for this pack of pills.
If it's not possible to obtain a spare pack of pills in time, another option is to continue your current pack as normal, taking only 20 actives instead of 21 actives. You can then immediately begin the active pills of your next pack, skipping your hormone-free week from the first pack. This ensures that you will have had at least 21 days of active hormones before having your hormone-free week. If you use this method, you should note that one side effect of it may be that you'll skip your period that month or that you'll experience cycle irregularities because of it, though it's something no one can predict for certain. What we can say is that the presence or absence of such side effects does not mean your HBC is not working. If you continue to take your HBC correctly, you are statistically very well protected against pregnancy.
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When do I need back-up protection?
It's very important to read your pill pamphlet thoroughly when you begin a new method of birth control, and this is a great time to refer back to it. A general guideline: you need backup protection (a condom or whatever else floats your boat) when you are on certain antibiotics or other prescribed medications (consult an online drug interaction checker, or check with your doctor or pharmacist), when you have missed a pill or pills (some brands recommend backup protection if you miss even one pill - again, check your pamphlet to see if this applies to you), when you extend your placebo/off week beyond 7 days, or when you've just begun a certain method if you were a Sunday starter or a quick starter until your method becomes fully effective (this is for your first pack only).
When your protection has been interrupted by missed pills, consult your pill information insert and follow directions for taking those missed pills and for using a back-up method of contraception. Good general guidelines are that back-up protection is required for 7 days after missed combined hormone contraceptives and for 48 hours after a missed progestin-only pill.
When your protection has been compromised by taking antibiotics, to be safest, you should use backup protection for the duration of the time that the interfering medication is in your system; this time may extend past when you're actively taking the interfering medication and may vary depending on what medication you've been taking. (Check with your pharmacist or health care provider for information about your specific medication.) In addition, after this period, you should wait until 7 days of uncompromised, active hormones have been supplied to your body to consider yourself fully protected once again. Until this time, it is safer to use a backup method of birth control. You may also refer to your HBC information insert to find guidelines that pertain to your specific brand of HBC.
What about diarrhea and/or vomiting?
According to the Population Reports Sidebars, 2 hours' time is sufficient for the hormones in the pill to be absorbed without compromising contraceptive effectiveness; for specific information as to whether your pill advises this same action, check your patient insert. As a general precaution, if you vomit or experience diarrhea within 2 hours of taking an oral contraceptive, you should consider that pill "missed" and act accordingly. In addition, women who experience vomiting or diarrhea as a repeating symptom of an illness are advised to use backup protection for 7 to 14 days after the illness.
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What about when switching brands?
Probably not, but stay tuned for specifics.
- When switching to combined oral contraceptives, the Evra or Ortho Evra patch, or Nuva Ring from another hormonal method, a back-up method is not required as long as the previous hormonal contraceptive was used consistently and correctly.
- When switching to progestin-only pills from another hormonal method, a back-up method is not required if the previous method was used consistently and correctly.
- When switching to Depo Provera from another hormonal method, a back-up method is not required if the previous contraceptive was used consistently and correctly.
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Does HBC protect against sexually transmitted infections (STIs)?
No, hormonal birth control doesn't offer any protection against infections. Condoms offer protection against most STIs, so always use a condom if STI status is in doubt, and make sure you and your partner(s) get tested regularly.
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What can interfere with my HBC?
When taking any medication, it's always a good idea to discuss possible HBC interactions with your doctor or your pharmacist. Some online sources, such as this report from the UK's Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit (links to PDF document) and this drug interaction checker are also good starting points.
Prescription Medications and Herbal Supplements
A brief overview of the basics:
Antibiotics--The antibiotics rifampicin and rifabutin have been shown to interfere with the effectiveness of most hormonal contraceptives, though they don't appear to reduce the effectiveness of Depo Provera or the Mirena IUD. The evidence for other antibiotics is inconclusive, so it's best to discuss them with your doctor or pharmacist, and/or to use a backup method "just in case." (Source: FFPRHC)
Anti-Epilepsy Medications--"Carbamazepine, oxcarbazepine, phenytoin, phenobarbitol, primidone, and topiramate all interact. (These drugs may also be used for control of bipolar disorder) Your doctor may recommend a high-dose pill, or a backup method." (VPer smallstar mentioned this in this comment, which is also supported by the FFPRHC)
Antifungals--Most (like the commonly prescribed fluconazole and OTC yeast infection treatments) will have no effect on HBC. However, the antifungal griseofulvin will. (FFPRHC)
Antiretrovirals--These are the drugs commonly used to treat HIV. Some of them will interact with HBC while some do not. Discuss specific medications with your doctor or pharmacist.
Barbiturates--Some barbiturates fall into the category of anti-seizure medications. However, some, such as butalbital (found in medications such as Fiorinal), can be found in muscle relaxers and/or medications to treat migraines. According to Health A to Z and other sources, barbiturates reduce the effectiveness of birth control pills. Backup protection is recommended.
St. John's Wort--According to Contraception Online, there have been small studies done in the UK and in Sweden in which some women taking both St. John's Wort and oral contraceptive pills experienced breathrough bleeding and/or unintended pregnancies. Though these studies were small, it is generally recommended that women not combine the use of St. John's Wort and HBC if they are relying on HBC for cycle regulation or pregnancy prevention.
Other Drugs and Herbal Supplements--To be safe, check each product with a doctor, pharmacist or herbalist before beginning the new treatment.
Topical Yeast Infection Treatments
Though it may only be of particular concern for Nuva Ring users, it is beneficial to note that according to the Nuva Ring Patient Information (PDF file), "Use of... vaginal yeast products will not alter the contraceptive efficacy of Nuva Ring."
Alcohol and Marijuana
There is no evidence to suggest that either drinking alcohol (from Teenwire) or smoking marijuana (from UCSB's SexInfo) decrease the efficacy of hormonal contraceptives. However, if, due to either of these substances, you forget to take a pill or you vomit shortly after (within an hour or two) of taking it, 'that' could interfere with the effectiveness of your HBC.
Weight?
There is some evidence suggesting that hormonal birth control may be less effective for women who are overweight or who weigh more.
For example, Ortho Evra users who weigh over 198 pounds are enouraged to speak to their doctors about the need for a backup and/or alternate method of contraception.
For other types of HBC, the evidence is minimal and conflicting. According to US News & World Report, a study reported an increased risk of pregnancy for women with a body mass index (BMI) of greater than 27.3; the exact cause for this increase, however, is unknown.
Many health care professionals believe that current evidence does not necessitate different prescribing guidelines for women with higher BMIs:
- Overweight and on the Pill? (from CBS News)
- Are low-dose pills effective for heavier women with low to normal BMIs? (from Managing Contraception)
- Are NuvaRings ineffective in very overweight women? (also from Managing Contraception)
- If I'm overweight and on POPs, do I need to take 2 pills in order for them to be effective? (Managing Contraception)
If you're concerned that your HBC may not be as effective because of weight, you may wish to discuss these concerns with your doctor.
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What about generic versions of HBC? Are they safe?
Yes, generic versions of hormonal birth control are safe and as effective as their brand-name counterparts. Do note however, the formulary for generic medications in the US may differ up to 25% from the brand name, and generics can have different colorings and fillers, which can affect some women who are particularly sensitive to such things. In addition, some types of HBC methods, such as the patch, shot, ring, and newer brands of pills may not yet have generic equivalents.
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So, I've heard that HBC works by making my body think it is pregnant. Does that mean pregnancy tests won't work right while I am using HBC?
Actually, hormonal birth control technically does not work by making the body think it is pregnant. According to ncsu_lady:
"It makes the body think it has already ovulated so that it does not need to ovulate again."
Also, pregnancy tests look for a certain hormone (HCG) that is only present in women when they are pregnant or taking certain types of prescribed fertility drugs. Hormonal birth control contains estrogen and/or progestin, but it does not contain HCG or cause your body to produce it. For that reason, pregnancy tests will still be accurate when you are using HBC.
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What if I think I might be pregnant? Do I continue taking my HBC?
According to the Mayo Clinic, if you didn't realize you were pregnant and continued taking your HBC, "don't be alarmed. Despite years of this accident happening, there's very little evidence that exposure to the hormones in birth control pills causes birth defects."
In addition, Contraception Online provides the summary of a 1990 meta-analysis of various studies, which offers more conclusive evidence:
"These data provide strong evidence that exposure to OCs in early pregnancy does not result in birth defects. Furthermore, the progestin dosage of current OCs is so low that the hormone pose no risk of causing masculinization of a female fetus. A woman who inadvertently takes OCs prior to or at the time of conception, or in early pregnancy, should be reassured that OCs do not cause birth defects."
| The US FDA & "Category X"
The US Food and Drug Administration currently classifies HBC as a Category X medication, which means that it is contraindicated during pregnancy. In general, this can mean the risks associated with the medication outweigh the benefits. However, according to Pregnancy and the Drug Dilemma, another web page from the FDA, oral contraceptives "land in Category X simply because there is no reason to use them in pregnancy." |
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I've decided that I want to stop taking HBC... Now what?
When can I stop my HBC?
Just like you can start taking HBC at any time during your cycle, you can also discontinue use at any time during a cycle. It's possible that waiting until the end of a pack will make it less likely that you'll experience menstrual irregularities, but this is not a guarantee.
What effects can I experience as my body adjusts to being off HBC?
Again, this is one of those very personal and individual responses. Just as no one can predict your side effects while starting HBC, no one can predict your side effects from stopping it. As VP SSM jennifer0246 explains here:
"Basically, it's possible that you will go back to exactly the way you were before hormonal birth control, or it's possible that your body will have changed enough in the intervening years that things will be pretty different for you. It's tough to say - most women go on hormonal birth control sometime in their adolescence, while their body is still changing and developing, and then go off in their twenties - due to all the changes taking place, plus the fact that every body is completely different, it's a really hard thing to predict."
During the adjustment process, which can last several months, you may experience irregular menstrual cycles as the hormones work their way out of your system. This can include longer, shorter, or irregular cycles as well as longer, shorter, or even missed periods; for a general timeline of when you can expect your "typical" cycles to return -- though keep in mind that your experience may differ -- you can check this page from the Mayo Clinic. If your goal is still to avoid pregnancy, it is best to begin another method of contraception immediately upon discontinuing HBC.
Additionally, as anecdotal evidence like this VP on LJ conversation suggests, some women may also experience emotional or mood changes as they adjust to stopping HBC. How long these changes last -- or whether you'll experience them at all -- is something that will vary according to individual body chemistry.
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NOTES AND DISCLAIMERS: This FAQ (and VP) is no substitute for medical care. Much of the information above has been adapted from the indicated sources. Click on the links to see their original text or to get more information. Any non-quoted items come from the VP Team's personal experience, which, again, is no substitute for medical care. As always, there is a limit to the information internet resources can provide; if you require additional assistance, it's best to contact an appropriate professional.