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Although birth control pills are by far the most popular form of hormonal contraception in the United States and Europe, other available forms include injections (Depo-Provera), hormonal implants, and morning-after contraception (Preven, or special dosages of oral contraceptives). All hormonal contraception is reversible; you can stop taking it and get pregnant, but implants and shots remain effective for months and years, requiring less attention than birth control pills. The hormones used in these methods can cause side effects, generally those associated with the normal menstrual cycle (breakthrough bleeding, queasiness, breast tenderness, acne, headaches, weight gain, and mood changes), but all have been tested for long-term safety. Before you begin to use any of these methods, you should have a checkup and alert your doctor if you have certain medical conditions — for example, a history of problems with blood clots.

Birth Control Pills

What is the reliability of combination birth control pills?

The theoretical success rate of combination birth control pills when taken consistently

and conscientiously is 99 percent. The success rate with typical use is also quite high, about 97 percent. The progestin-only minipill has a theoretical effectiveness rate of 98 percent and an actual rate of 96 percent. Some people believe that low-dose pills are more likely to fail than the old-fashioned pills with more estrogen, but one of my patients who was taking a 50-g pill (a high-dose pill for this day and age) did become pregnant, so estrogen dose level is no guarantee of success.

Do you need to have any tests in order to get birth control pills?

Your health care professional will want to do a physical exam, including a pelvic exam, a Pap test, and a breast exam.Your caregiver will check your blood pressure and ask whether you have had clotting problems, heart disease, stroke, breast cancer, or diabetes. You will be reminded that oral contraceptives do not protect you from sexually transmitted diseases.

You may be asked to have a follow-up appointment several months after you start

taking oral contraceptives, to monitor your blood pressure and check for side effects.

Do other medications interfere with the effectiveness of birth control pills?

While it is always worth telling the doctor who is treating you for some other problem that you are taking oral contraceptives, most other medications do not interfere with the action of birth control pills. Even a week’s worth of an ordinary antibiotic will probably not decrease their effectiveness, though it is worth checking with your doctor about backup contraception (some manufacturers warn about reduced effectiveness with ampicillin and tetracycline). Rifampin, an antibiotic prescribed to treat tuberculosis, interferes with oral contraceptives, so tell your gynecologist of the possible conflict. If you are taking something like Dilantin or phenobarbital for seizures, you might need a higher-dose pill. Although there is not much scientific evidence one way or the other, it is reasonable to assume that since most medications manufactured by pharmaceutical companies do not interfere with the action of oral contraceptives, most herbal medications will not do so either. Recently, however, some researchers have questioned whether Saint John’s-wort reduces the effectiveness of oral contraceptives; check with your doctor.

Are there reasons not to take birth, control pills?

If you are over 35 and smoke, you seriously increase your risk for heart attack and stroke by taking oral contraceptives. Smokers of any age have higher rates of heart attack and stroke than nonsmokers; smokers who take birth control pills are at greater risk than smokers who use other contraceptives. Many physicians feel that heavy smokers should not use oral contraceptives at any age; others believe that moderate smokers younger than 35 can safely use them. Since oral contraceptives are so safe and effective for nonsmokers, being able to use them throughout your reproductive life is one of the many excellent reasons for not smoking.

If you have had clotting disorders (for example, thrombophlebitis), breast or uterine cancer, severe liver disease, heart disease, stroke, or high cholesterol, your doctor probably will not recommend oral contraceptives. If you have sickle-cell disease, you should consider alternative forms of birth control. If you have migraine headaches, high blood pressure, or depression, tell your caregiver when discussing contraception.

Can you take birth control pills if you are diabetic?

Because the progestins in birth control pills can change the way the body processes glucose, oral contraceptives may cause problems for women with diabetes. Some forms of pro-gestin (for example, norethindrone) seem to have less effect than others. Diabetic women may have to adjust their insulin while taking oral contraceptives, and they should be carefully monitored by their physicians. Diabetic women are at increased risk for cardiovascular disease, and progestin is associated with such complications as high blood pressure, lowered high-density lipoprotein and elevated low-density lipoprotein. Pregnancy can cause special problems for diabetic women, and birth control pills are one of the most reliable methods of avoiding accidental pregnancies.

Can you take birth control pills while you are nursing?

The American Academy of Pediatrics does approve of their use, but consult your pediatrician. Possible side effects include decreased milk production. Many pediatricians prefer that mothers use a progestin-only pill until they finish nursing.

Can you take birth control pills to relieve hot flashes and other symptoms if you are approaching menopause?

Birth control pills can effectively ease the symptoms surrounding the onset of menopause, including hot flashes, irregular periods, and heavy bleeding, while also providing contraception. health maintenance organizations will often pay for estrogen replacement therapy; but if the pills are being used for birth control, there is less hope for reimbursement. When one of my patients has had her tubes tied, I send a note documenting the surgery and point out that there is no possibility that she is using the pills for contraception.

What is the schedule for taking birth control pills?

Since oral contraceptives only work if you take them, the best schedule for you is the one that helps you remember. For this reason and to keep the dosage consistent, try to take your pill at the same time every day. It does not really matter whether this time is morning or night, unless the estrogen in the pills makes you queasy, in which case it is probably better to take the pill with dinner or at night before you go to bed.

Combination pills come in packets of either twenty-one pills or twenty-eight pills. The twenty-eight-pill packs contain twenty-one pills with estrogen and progestin and seven placebos; you take one pill every day, all month long. The twenty-one-pill packets contain twenty-one hormone pills; you take them until they are gone, then wait seven days and start again, even if you are still bleeding. In either case you get twenty-one days of combined hormones and seven days without hormones.

Some brands are designed so that you take the first pill on the first day of your period. With other brands you begin the Sunday after your period starts. The exact date does not matter, as long as it is close to the time of your period.

The progestin-only pills are taken thirty days out of thirty, even during your period.

Are you protected from pregnancy during the week you are not taking birth controlpills (ifyour brand comes in the twenty-one-day packs)?

Yes, because the twenty-one pills you’ve already taken have blocked ovulation for that month. However, if you fail to start the pills again for an extra week after your “week off,” your ovaries may have gotten back on schedule and be ready to send forth an egg.

Are generic birth controlpills safe?

I prescribe generic drugs whenever I can. Bylaw, the compounds in generic drugs must be as pure as those in brand-name drugs, but the amount in each generic pill may vary a little more from one pill to another. For example, Premarin, a type of estrogen used in hormone replacement therapy for postmenopausal women, was originally marketed by the Wyeth-Ayerst Company, which prided itself that the amount of hormone varied no more than 3 percent from pill to pill. Today there is a generic contraceptive containing the same type of estrogen, but the quantity can vary plus or minus 10 percent from pill to pill, a 20 percent change overall. This amount of variation does not interfere with the pill’s effectiveness.

Will birth control pills protect against pregnancy the first month you take them?

Although pills are probably effective the first month if you start them on the first day of your period, it is easy to forget to take a pill or two before you establish the habit. Therefore, you would be wise to use a backup method of birth control the first month.

Can you take oral contraceptives if you are younger than 16 or older than 35?

Adolescents should wait until they have stopped growing before starting oral contraceptives, perhaps six months after their initial period. It used to be a firm, fast rule that women over age 35 could not use birth control pills, whether they smoked or not. Now many gynecologists have relaxed that view and allow (or even encourage) older women to use oral contraceptives, as long as they do not smoke or have a history of heart disease or stroke, high blood pressure, or liver disease.

How long can you stay on the pill?

You can stay on the pill as long as you feel comfortable with it. Speaking for myself, I have been taking birth control pills for more than twenty-five years, because I like knowing when my period will come and I like having no cramps. I see no reason not to continue on them until menopause.

Do birth control pills pose long-term health risks?

Physicians and researchers have studied this problem extensively; so far there are no indications of widespread danger (unless you smoke), despite the fact that in the early 1970s some feminists accused researchers of using women’s bodies as “living laboratories” to test the pill’s safety.

Early in its history, when the pill contained much higher levels of hormones, oral contraceptives were linked to blood clots, which can cause strokes, heart attacks, or other circulatory problems. Now that the estrogen content has been reduced to 35 µg or less, oral contraceptives do not seem to increase the risk of these diseases, except for smokers.

Do birth control pills offer any long-term health benefits?

Do oral contraceptives increase the risk for breast or cervical cancer?

There is no solid evidence that oral contraceptives raise the risk of breast cancer, even among women who took high-dose pills in the 1960s. Some studies in the early days of oral contraceptives did link the pill to a higher incidence of cervical cancer, but other factors may be at work. First, barrier methods do lower the risk of cervical cancer, but women who take the pill are less likely to use barrier methods also. Second, women who use oral contraceptives may begin sexual activity at an earlier age or have more sexual partners than women who do not (both factors increase risk). Later studies designed to take into account these other factors did not show that oral contraceptives increase risk.

Do oral contraceptives cause high blood pressure?

About 5 percent of women who did not previously have high blood pressure (hypertension) develop it after several months of taking birth control pills. Some of the more recently developed pills seem to have less of an impact on blood pressure than the earlier ones did. The small possibility of developing hypertension is one of the reasons you should have regular checkups if you take birth control pills. If you are unfortunate enough to develop high blood pressure from taking the pill, you will probably have to choose a different method of contraception.

What are the side effects of oral contraceptives?

Nausea or queasiness is probably the most common one. Bloating and weight gain is another. Taking oral contraceptives is not going to make you put on fifteen or twenty pounds (unless you change your eating or exercise habits), but some women gain two or three pounds of fluid weight when they start taking birth control pills, just as women sometimes do on estrogen replacement therapy. If you become bloated when you start taking oral contraceptives, try a different brand or a pill with a different combination of hormones. A new pill called Yasmin has a type of progestin that actually acts as a diuretic as well, decreasing fluid retention for women who have this problem. Other side effects include breast tenderness, skin problems, including rashes or eczema, and brown patches on the face.

Do birth control pills reduce sex drive?

Some women think that birth control pills do lower their libido; some notice no difference; still others find that freedom from the fear of pregnancy increases their sexual desire. If depressed libido is a problem, try a pill that contains either norgestrel or levonorgestrel for its progestin. These pills may boost your sex drive because the progestin they contain is a little more androgenic — that is, a little more like male sex hormones — than other progestins. But while some women report increased sex drive with these pills, others do not notice any difference.

Table Birth Control Pills and Sex Drive

More Androcenic

(may increase sex drive)

Less Androcenic

(may decrease sex drive)

Levlen (levonorgestrel) Desogen (desogestrel)
Lo Ovral (norgestrel) Ortho-Cept (desogestrel)
Nordette (levonorgestrel) Ortho-Cyclen (norgestimate)
Ovral (norgestrel) OrthoTri-Cyclen (norgestimate)
  Yasmin (drosipirenone)

Women who use progestin-only pills may have irregular periods and start bleeding anytime during the month. Some bleed quite heavily, others continue to have normal cycles, and some do not bleed at all.

What should you do if you forget to take a pill?

If you miss one pill, take two the next day; you should still be protected. If you forget more than one pill, use a backup method of contraception.

If you bleed between periods while you retaking oral contraceptives, does it mean that the pills aren’t working?

Spotting or bleeding when you do not have your period (breakthrough bleeding) is fairly common for women taking the pill. Even if it happens, the pills are still working. If you take your low-dose pills at significantly different times of day (one in the morning and the next one late at night the following day), you may have breakthrough bleeding. If the bleeding continues even when you take your pill at the same time every day, call your physician. Another brand or another formulation of the pill may solve the problem, but some women find breakthrough bleeding so annoying that they change contraceptive methods.

How much do birth control pills cost?

Most birth control pills cost between twenty and twenty-five dollars monthly, plus the cost of an annual checkup visit to your caregiver. Some health maintenance organizations will pay for oral contraceptives, just as they pay for other prescriptions, but many do not. If your health plan does not pay, check prices of the pharmacies in your town, because there is some variation from one drugstore to the next. Or try calling femScript (1-800-511-1314), an organization that provides discount birth control pills. After a $9.95 sign-up fee, all products offered by femScript are significantly discounted. Women’s advocacy groups are currently pushing for legislation that will cover contraceptives, though their efforts have not yet succeeded in all states.

Do birth control pills make it more difficult to become pregnant when you stop taking them?

Although some scientific studies have suggested there might be a delay of several months before ovulation begins, particularly for older women, other studies show no such evidence. By protecting you against pelvic inflammatory disease and possibly endometriosis, the pill may even enhance your fertility.

I always tell my patients to use another method of birth control after they stop the pill unless they want to become pregnant immediately. When I tried to get pregnant with my first child, I had been using birth control pills for about fifteen years. I stopped the pill for three months, then got pregnant my second month of trying.

Do your menstrual periods return immediately after you stop taking birth control pills?

Some women have a delay of two or three months before ovulation and menstrual periods begin again. Others begin ovulating right away. Some women, whether they have been taking oral contraceptives or not, spontaneously stop having periods, so it is difficult to tell whether the cause is the pill or something else.

Many physicians recommend a three-month wait after stopping the pill before trying to become pregnant. Some studies have suggested that there may be a higher rate of twins conceived in the first one or two cycles after going off the pill.

Do birth control pills preserve fertility by preventing ovulation and thus “saving” eggs for later use?

The ovaries are formed during fetal life, as are the eggs inside them. The future baby girl carries within her immature ovaries about a million eggs. This number drops to about four hundred thousand at birth, and only a fraction of these are destined to reach maturity — maybe about four hundred. So in the reduction from four hundred thousand to four hundred, the ovulations that are suppressed by birth control pills make little difference.

Depo-Provera

Lunelle

Lunelle, long widely used in Latin America, was cleared for use in the United States in 2000. Like oral contraceptives, it combines estrogen and progesterone but is given as a monthly injection. You still have menstrual periods but you do not conceive. The product is almost 100 percent effective and has minimal side effects. Unlike Depo-Provera, which may take months to wear off, Lunelle is easily reversible. The major drawback is that you need to get a shot every four weeks. In many states, pharmacists can give injections, so you need not necessarily go to your doctor’s office for the shot. While Lunelle was being developed, researchers discovered that many women would rather have a monthly shot than take a daily pill.

Hormonal implants

A new form of hormonal contraception, Norplant, was introduced in 1990. Developed by the Population Council, a research foundation that works primarily in developing countries, Norplant offered a new option for convenient, long-acting, and reversible contraception. Norplant prevented conception by blocking ovulation and thickening the cervical mucus, thus discouraging sperm on its journey to fertilize the egg.

Hormonal implant — Norplant came as a set of six flexible silicone capsules, like tiny matchsticks, which were inserted surgically under the skin of the upper arm.

Figure Hormonal implants release a small, continuous dose of the hormone progestin, which provides contraceptive protection for about three years

Figure Hormonal implants release a small, continuous dose of the hormone progestin, which provides contraceptive protection for about three years

The capsules contained levonorgestrel, a synthetic form of progesterone, the hormone produced during the second half of the menstrual cycle. The progestin was released gradually, preventing pregnancy for as long as five years, though the length of effectiveness varied according to body weight and metabolism. The capsules could remain in place for five years and then be removed and either replaced or discontinued. Norplant delivered a very low dosage of progestin and contained no estrogen.

Hailed as a great innovation, Norplant became embroiled in controversy. In 2002, the manufacturer took it off the market because of unpleasant side effects — mainly unpredictable bleeding — and occasional difficulties with removal. A new implant, Implanon, is being developed and will probably be available soon in the United States. It consists of a single soft plastic rod about the size of a matchstick and will be effective for three years instead of five.

How are hormonal implants put in?

Any physician, nurse-practitioner, or other health care professional who has been trained can do the insertion and removal. Be sure your caregiver has received the proper training before you have the procedure. Because you want to be certain you are not pregnant, you should have the insertion within the first week of the start of a normal menstrual period.

The procedure can be done in an office setting and takes only a few minutes. Your caregiver will anesthetize your upper arm with a local anesthetic, make a small incision through the skin, and place the implant beneath the skin using a disposable inserter. The incision will be closed with tape (stitches usually aren’t necessary) and covered with a bandage.

The implant site may be sore for a day or so and may swell or look bruised. If the swelling or bruising persists, inform your caregiver. Once the initial soreness has disappeared, you may be unaware of the implant or you may feel a bump or ridge above it. The implant will stay put under your skin and will not move around. It is flexible and won’t break if bumped or if pressure is put on it during normal activities.

How are hormonal implants removed?

While removing Norplant usually took less than half an hour and rarely left a scar, sometimes the capsules became embedded in scar tissue under the skin. I had to take one woman to the operating room and remove the implants under general anesthesia because she was just too uncomfortable otherwise. This was a rare complication, but it was a concern with Norplant. Preliminary studies suggest that the design of Implanon will make insertion and removal quicker and easier.

Can the implants be removed before or after the designated time period?

You can have the capsules removed any time you wish if you are unhappy with them or their side effects. While they should be removed at the time the manufacturer advises, nothing dangerous will happen if you delay for a few months. However, hormonal implants gradually lose effectiveness, so your risk of pregnancy increases. A study of Chinese women with an average weight of about 120 pounds showed a cumulative pregnancy rate of 2.3 per 100 women at the end of seven (instead of the recommended five) years of Norplant use.

Is the implanted plastic rod dangerous?

The furor over the safety of silicone breast implants has made many women worry about implants of any kind. The Implanon rod is made of ethylene vinyl acetate, not silicone. But if the notion of having a foreign substance implanted in your body makes you anxious, you should probably try a different form of contraception.

Will you get menstrual periods with hormonal implants?

Many women didn’t get periods with Norplant and were very happy with the situation. However, as with other progestin-only contraceptives including the minipill and Depo-Provera, women varied in their responses. Some women had so much bleeding that after six months they had the capsules removed.

What are the side effects?

The new hormonal implants can be expected to have the same side effects as Norplant, Depo-Provera, and other progestin-only contraceptives. These include changes in menstrual bleeding patterns, lack of periods, or spotting and staining between periods. Twenty-seven percent of women using Norplant reported frequent bleeding or prolonged periods, with an average of one hundred days of bleeding during the first year. A smaller number of women had headaches, skin problems, nausea and appetite changes, weight gain, and nervousness or irritability.

Do hormonal implants impair fertility once they are removed?

One advantage of hormonal implants is their quick reversibility. With Norplant, the contraceptive action stopped within two or three days after the implants were removed. More than 75 percent of women who wanted to become pregnant did so within the first year after removal. This rate is higher than the fertility rate in the general population.

Are there reasons for not using hormonal implants?

If you have active liver disease and possibly phlebitis (blood clots in the veins), you should not use this form of contraception. Other conditions you should mention to your care-giver are unexplained vaginal bleeding and a history of breast cancer. You should not have the capsules inserted if there is a possibility you are pregnant.

How much do hormonal implants cost?

The new implants will soon be on the market in the United States. Norplant had a high up-front cost in this country — between five hundred and six hundred dollars for the implantation procedure — though it was considerably less expensive elsewhere. Many insurers do not cover contraception, so women may have to pay out of pocket. If the cost of implants is spread over their effective life, it is less than the cost of birth control pills.

How reliable are hormonal implants?

Hormonal implants are among the most reliable contraceptives available, more than 99 percent effective in terms of both best-expected effectiveness and typical use. Once the implant has been inserted, you do not have to think about it; there is no chance for human error. It becomes effective within twenty-four hours, so you may have intercourse without backup contraception a day later.

Statisticians collecting data on contraceptive effectiveness usually look only at the first year of use. For Norplant, statistically speaking, the failure rate in the first year was only one in five hundred. The failure rate went up slightly during the five years Norplant remained in place, rising to two in five hundred by the fifth year of use, with overweight women having greater risk of pregnancy than thin women.

Are hormonal implants right for you?

Because implants are so long-lasting, they are ideal for women who do not want more children, or do not want them for several years. Women who are looking for reversible contraception but do not want or cannot use an intrauterine device might choose implants. There are other, sadder reasons for using this contraceptive as well.

Nicole, one of my middle-aged patients, has a teenage daughter, Angela, who runs away regularly and is sexually promiscuous. Angela sees a therapist and receives psychological counseling and other supportive treatment, but continues her risky behavior. Nicole worries that Angela may become pregnant or infected with an sexually transmitted disease. When she finally realizes that she cannot change Angela’s behavior, she urges Angela to have a Norplant and Angela agrees. While the Norplant does not guard against sexually transmitted diseases, Angela is at least protected against pregnancy.


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