The name sounds pretty simple — the pill — and yet with so many options it can be overwhelming to choose the right birth control for you. We break it all down so you don’t have to get lost in the bowels of WebMD, searching for what should be an easy solution. Let’s help you set it and forget it.
Combined estrogen-progestin oral contraceptives (COCs) are also known as birth control pills or “the pill.” COCs contain an estrogen and a progesterone component, both of which are hormones produced mainly by the ovaries. All COCs are equally effective when taken correctly, which is at the same time daily. Low-dose COCs are a safe and reliable contraceptive option for the vast majority of women.
COCs have many advantages including rapid reversibility (you can stop the pill if you want to get pregnant), regulation of menstrual bleeding (more regular and hopefully decreased flow), less cramping (yes, please!), and potentially lower risk of certain cancers such as uterine and ovarian cancer. But mainly, COCs are used to prevent undesired pregnancies.
We prefer generic COCs because they’re more affordable. Brand name COCs are more expensive out-of-pocket and there is no evidence that generic COCs are less effective than the brand name ones.
Our doctors recommend monophasic pills (like Alesse®/Alysena or Marvelon®/Mirvala), which means each active pill has the same hormone dosing. These tend to be easier to use and offer a consistent hormone dose.
Multiphasic COCs (like Tricyclen®/Tricira) were first introduced as an attempt to reduce hormone-related side effects and unscheduled bleeding. But there’s no data that they have any important advantages over monophasic pills. There are a couple of shortcomings of multiphasic COCs. Firstly, you need to be more careful about the order in which you take the pills. Secondly, you can’t take pill packages back-to-back in order to skip a period. Also, the changing hormone levels in multiphasic COCs can make low mood symptoms worse in some women.
Some women use a multiphasic pill and like it. Felix doctors are happy to prescribe multiphasic pills to women who prefer them based on experience, but in general they prefer to prescribe monophasic pills given the consistent level of hormones and ability to skip periods.
Alysena is a commonly prescribed low-dose COC with only 20 mcg ethinyl estradiol (synthetic estrogen) and a progesterone called levonorgestrel.
Keeping the estrogen content lower helps prevent side effects like headaches, breast tenderness or mood changes. That being said, lower estrogen means you may get spotting. If you have breakthrough spotting on Alysena, you may want to increase the estrogen dose to something like Mirvala, which has 30 mcg ethinyl estradiol and a progesterone called desogestrel. Other birth control formulations are available with different types of progesterone, like Lolo and Yaz. When choosing a birth control pill, it’s normal to experience a bit of trial and error. All of them work, but sometimes it’s about tailoring how you feel on any given pill.
At Felix, we also offer the contraceptive ring, called Nuvaring. It’s a small silicone ring you insert into your vagina (like you would a tampon, but way easier) for three weeks, then remove for one week to have your period. You and your partner should not feel it during sex, and it’s easy to insert and remove. It eliminates remembering your pill every day, but you’ll have to set a reminder about the removal date in your phone or calendar. Because the hormones are absorbed into your system through the vagina and not through the digestive system (when taking a pill), some women may experience fewer side effects.
We also offer the birth control patch, called Evra. You apply one patch weekly for three weeks, on your buttocks, abdomen, upper outer arm, or back — followed by a patch-free week when you have your period. Important note: the topical patch may be less effective in patients weighing over 200 lbs.
Patients may experience breast tenderness, headaches, nausea, and bloating when starting a COC. These symptoms typically resolve quickly. Sometimes in the first three months, you might have unscheduled bleeding (spotting, or periods at unexpected times), which usually clears up. Some people report low mood or decreased libido when taking COCs. And although there’s a lot of patient concern over this, there’s no evidence that COCs cause weight gain.
Good to note: be patient when taking COCs for the first time as it may take a few weeks to adjust to the new medication.
Women aged 35+ and who smoke more than 15 cigarettes a day can’t use estrogen due to increased risk of blood clots. Our doctors also don’t recommend estrogen containing birth control if you have a history of blood clots, migraines with aura, high blood pressure, heart disease, breast or liver cancer, liver disease, or a long history of diabetes. For people who fall into these categories, the progesterone-only pill (POP) or the progestin-containing intrauterine device (IUD) are great birth control options.
The progesterone-only pill (like Movisse®/Micronor) doesn’t contain estrogen. It’s slightly less effective than a COC, and it must be taken at the same time every day to be effective. You may not get a period while taking a POP, which is expected and completely normal. If you can’t take estrogen, you can also consider using copper or progesterone-based IUDs or condoms for birth control. These pills may not be as effective as COCs in preventing pregnancy, especially if not taken at the same time every day. Some women use condoms as a backup when using POPs.
Continuous or extended-cycle COC regimens allow you to choose if and when to have a period. Skipping periods on the pill is safe. If you’re taking a regular 28-day package, you can just skip the last 7 inactive pills and move straight into your next package of active pills to skip a period. Some pill packs have fewer pill-free days, so be sure to read the pack instructions first.
Extended-cycle preparations (like Seasonale) are actually packaged so you take 84 active pills in a row and automatically have no periods.
We recommend the “quick start method” which means you begin taking COCs the day that you get the prescription. You can safely start your birth control on any day of your cycle. Be sure to use back up (like condoms) for two weeks after you start the pill to prevent pregnancy.
Sexandu.ca does an incredible job guiding women through this, providing advice and planning based on their individual scenario. This site was created by the Society of Obstetricians and Gynaecologists of Canada so it’s a very trusted source. In general, if you miss a pill, take it as soon as you remember and use a back up contraception like condoms for a week.
Hormonal contraception can be continued until menopause (average age 50) in healthy, non-smoking, normal weight women. There is no need to take time off from the pill, or change which pill you take. Women can use COCs for years and stop only for pregnancy or menopause.
We’re big fans of sexandu.ca for info and resources around birth control and more!
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The views expressed here are those of the author and, as with the rest of the content on Active Ingredients, are not a substitute for professional medical advice, diagnosis, or treatment. If you have any medical questions or concerns, please talk to your healthcare provider.