How to Choose the Right Birth Control Pill for You

Posted on September 1, 2023 by resourcefulman

The “pill” is not a monolith: there are hundreds of birth control pills, and they are not all the same. But many people are never given a choice. They come to the clinic, ask for a “pill” and receive a prescription that may or may not be the best for their particular situation. Considering how common this is, it’s no surprise that many of us believe “one size fits all” when it comes to birth control pills.

Perhaps that is why it seems that the hottest trend of the millennium at the moment is the rejection of birth control. While some people opt for long-acting methods like the IUD, others seem to be skeptical about hormonal contraceptives in general and the pill in particular, citing concerns about long-term safety and their impact on mental health.

Everyone has the right to make their own medical decisions, and refusing to take the pill for any reason is certainly considered as such. However, the Internet makes it all too easy for people to get all sorts of misconceptions about complex medical concepts like hormonal contraception. There is a lot of misinformation about what the pills really are, how they work and what risks they carry, and people are increasingly basing their contraceptive decisions on anecdotes and rumors rather than sound medical advice.

The science behind pills in all their various formulations is extremely complex, but you don’t need a degree course in reproductive endocrinology to understand your options – you just need to know that you have options. To help sort them out, I spoke with two OB/GYNs who specialize in family planning and contraception: Dr. Ann Davis, director of the Family Planning Scholarship at Columbia University, and Dr. Christine Brandi of Rutgers University.

A (Very) Brief History of Birth Control Pills

When we talk about pills, we usually mean combined oral contraceptives (COCs), which have been around since 1957. In many ways, they have not changed much: they still use a combination of progestin and estrogen, which are synthetic. versions of the hormones that control the menstrual cycle. When used together, these hormones prevent ovulation, thicken cervical mucus, and thin the lining of the uterus.

The very first combination pill, Enovid 10, contained a whopping 10 milligrams of a progestin called norethinodrel and 0.15 milligrams of an estrogen called mestranol. Both of these drugs were at least partially phased out by the mid-to-late 1960s, but their replacements, norethindrone (a progestin) and ethinyl estradiol (an estrogen), are still widely used today. However, modern dosages are much lower: a typical combination tablet today may contain 500–1000 micrograms of norethindrone and 20–50 micrograms of ethinyl estradiol. This is 5% to 10% of the Enovid 10 progestin dose and a third (or less) of the estrogen dose.

The choice of formulas has also expanded over the past 50 years. These days, you’re not limited to daily pills: Birth control patches and rings use the same combinations of hormones. Ethinyl estradiol is still the main estrogen, but your progestin options go beyond norethindrone today. Scientists have been looking for the perfect progestin for decades and have synthesized several other options over the years. Progestins are often classified into “generations” based on how long they have been around:

First generation: norethindrone, norethindrone acetate.
Second generation: levonorgestrel, norgestrel.
Third generation: desogestrel, norgestimate.
Fourth generation: Drospirenone.

Every progestin on the market is both safe and effective in preventing pregnancy, but there are some small differences. According to Brandi, first-generation progestins, especially norethindrone, are similar to testosterone, while the newer progestins barely resemble it. This can affect what side effects you can expect: “Many patients [who] use first-generation progestin … have a lot of so-called androgenic or ‘male’ side effects: acne, excess hair growth, weight gain, stuff like that.” ‘ she explains. “The newer [progestins] are so far removed from testosterone that they actually act as anti-testosterone or anti-androgen drugs.”

Davis points out two other disadvantages of norethindrone compared to the newer progestins: a short half-life and a relative inability to prevent ovulation. These are most noticeable with norethindrone-only pills with no estrogen at all (sometimes referred to as “mini pills”): “You have to take [norethindrone-only pills] at almost the same time each day , because the half-life is very short,” she says. “Also, the bleeding you’re going to have is unpredictable because [norethindrone] doesn’t suppress ovulation very well.” However, the estrogen in norethindrone combination pills neutralizes these effects enough to be usable for most people.

The key phrase here is “most people”. Davis emphasizes that the small differences between progestins are practically meaningless to the average user. As long as you take estrogen and some progestin every day, you are very unlikely to get pregnant, and the side effects of one pill are likely to be indistinguishable from the side effects of another. But many people rely on these side effects to treat painful periods and hormonal imbalances: “[Some] pills can specifically target certain side effects,” says Brandi. “And if you know how to do it, you can use [them] not only to prevent pregnancy, but also to relieve other symptoms that you may have.”

What do we know about side effects?

This brings us to the biggest, most complex and controversial aspect of the pill: side effects. In addition to serious medical conditions like blood clots, birth control pills are often blamed for everything from mood swings to weight gain and a general feeling of boredom. Some side effects are more studied than others, so let’s start with the ones we understand best: cancer and blood clots.

In general, pills reduce the risk of cancer

There is widespread concern about the link between birth control pills and cancer , but it is largely unfounded. While combination pills are associated with an increased risk of breast cancer, this is often cited as a separate statistic and not part of a much larger picture . Oral contraceptives significantly reduce the risk of ovarian, endometrial, and colorectal cancer. They are associated with an increased risk of breast cancer, but the increase is small and does not increase the longer you take the pills. The largest potential increase in risk associated with oral contraceptives is actually due to cervical cancer – and this risk does increase with continued use, according to one study . Davis sums it up beautifully: “On the whole, birth control pills prevent far more cancers than they could cause.”

It is perfectly reasonable to worry about cancer when choosing pills; cancer is terrible and no one wants that. But cancer is not caused by any one factor, and your birth control is unlikely to be the only factor that determines whether you get it. With that said, doctors take this very seriously – be sure to provide you with a complete medical history so they can decide if you’re a good candidate for the pill.

Pregnancy increases the risk of blood clots much more than pills

Elevated estrogen levels increase the risk of blood clots, meaning that any combined oral contraceptive could theoretically do the same. However, modern pill formulas contain such low doses of estrogen that the risk is minimal. As for progestins, they don’t affect your risk in one way or another; The exception is tablets containing drospirenone, in which the risk of blood clots increases by about three times compared to other tablets. If that sounds scary, remember that the absolute risk of blood clots is extremely low, even after this three-fold increase, and it still doesn’t come close to the increased risk during pregnancy and the first 12 weeks postpartum.

With that said, some people do have a higher baseline risk of blood clots than others, especially smokers over age 35. A family history of blood clots also increases your risk, as do certain types of heart disease and bed rest. But for the vast majority of people, the pill has little effect on the risk of blood clots.

Most pills relieve hormonal acne to some extent.

You may have seen some FDA-approved combination pills for acne. But, according to Davis, they all do this:

“Estrogen has a very strong antiandrogenic effect, [which] outweighs any differences in progestins related to their androgenicity. … If you take estrogen in the form of birth control pills, your testosterone levels will drop significantly. So if you have hormonally sensitive acne, you will feel better if you take a second, third or fourth generation progestin pill.”

While they can definitely work, Davis remains skeptical about some pills being advertised as acne treatments. “If [pharmaceutical companies] can prove that their medications help acne, they can sell them for acne. … And then they can say: here is our new pill, we tested it on [acne], and the FDA gave its approval.” This brings in new users and more money.

We don’t know for sure if one of these FDA-approved pills is more effective at treating acne than the rest; we just know they are better than placebo. All the data we have on the various androgenic effects comes from hormone receptor binding assays in cell cultures , not from direct clinical trials in living subjects. “No drug company wants to pay for a study that they lose,” as Davis put it. So while anecdotal evidence suggests that people with acne may be more comfortable with a new progestin such as norgestimate or drospirenone, this is not a hard and fast rule.

If you have unbearable periods, there may be a pill that will help.

The pills were originally marketed as a treatment for so-called “menstrual dysfunction” because birth control was quite taboo in the early 60s, but also because that’s technically their primary function. Combination pills prevent ovulation, which also means that they prevent menstruation. The pill allows you to control your period, not the other way around.

No other birth control method can compare to this. Progestin-only pills prevent fertilization but not necessarily ovulation , which can cause unpredictable bleeding. Hormonal IUDs containing the progestin levonorgestrel, but not estrogen, completely stop menstruation in some people, but not all. (The same goes for the injection and the implant, which, you guessed it, are also progestin-only methods.) Copper-containing IUDs cause persistent, mild inflammation in the uterus, which means they can cause even heavier and more painful periods. But the right combination of pills (or patch or ring) makes your periods lighter and easier and also allows you to choose when you bleed; if you never had a period again in your life , he might do it too. For people with endometriosis , premenstrual dysphoric disorder (PMDD) , polycystic ovary syndrome (PCOS) , irregular periods, or cramps severe enough to make them unable to work, the pill is a serious life-affirming drug.

We’ll probably never know for sure how pills affect mood.

In recent years, more attention has been paid to the relationship between hormonal contraception and mental health. So, once and for all: do pills cause depression – and if you already have it, can they make it worse?

There is no clear answer to this question. One 2016 Danish study found that oral contraceptive use was associated with a higher likelihood of using antidepressants and being diagnosed with depression first, especially among adolescents. However, this is not quite iron proof. This study was observational in nature, which means that it looked at an extremely large set of health data while adjusting for certain factors such as age, gender, location, and certain diagnoses. “Large datasets are good for having enough people in your study to look for small effects, but they are not good for finding out anything about an individual person in the study,” says Davis. This means that you can determine the frequency of diagnoses of depression, but not necessarily all other factors that contribute to this, except for the use of contraceptives. “If you don’t know a person’s family history [or] their baseline mental health … you can’t figure out all the other things that can also influence that person’s risk of depression.”

It is likely that hormonal drugs can affect our mood, but to prove this in a clinical setting is almost impossible. Long-term double-blind studies are incredibly expensive, and even if they were funded, they would still have to contend with confirmation bias and placebo effects—both of which are particularly strong with oral contraceptives.

You can associate the placebo effect with positive outcomes, but as Davis explains, the opposite can also be true. Negative placebo effects, called “nocebos”, crop up all the time in contraceptive research: “[In] some of the older studies, [subjects] were given an inert or active pill, and many [people] who took the inert pill had side effects.” They generally had the same side effects and the same frequency as people who took the real drugs.” Perhaps more than anything, she believes this shows how much of our everyday emotions we have learned to attribute to birth control, noting that “[we] have been taught from a very young age to identify certain feelings as ‘hormonal’.” After all, if you’re already in the mood to feel something, you’re more likely to actually feel it – so the more you read online about certain side effects, the easier it becomes to conclude that your pill is causing them.

All of this makes it extremely difficult for pill users to know if a change in mood is just a change in mood or if it is related to the medication in some way . Both you and your doctor need to trust your symptoms and be critical of what might be causing them.

“I’ve heard a lot of different stories about how people experience changes in mental health depending on what types of contraceptives they use,” says Brandi, “[and] I believe people who have these symptoms.” She says the best way to deal with this problem is to openly discuss it with your doctor so that he can adjust your dose or change the formula if necessary: “If someone has side effects from one pill, this does not mean that all pills will cause side effects. this is for them, but they may need a lower dose or a different progestin.”

How to find the right pill

The horrific experience of taking the first pill can make people stop taking it for life. Here’s what you need to know to minimize the chance of this happening.

Consider your period

All pills reliably prevent pregnancy, so if you want to find a pill that relieves certain menstrual symptoms, your doctor needs to know as much as possible about your cycle. Here are just some of the questions Davis is likely to ask his patients:

“How much are you bleeding? Does it hurt you? Do you want to see [your periods] every month? Would you be all right if you didn’t? Would you rather not? Would you like to see it once in a while, or would it be okay if you never get your period? Would you like to never have a period?”

Based on the answers to these questions, she will determine the starting point: “Let’s look at how the pills are formulated and choose the one in which you are most likely to get the [effects] you are looking for.”

If you don’t have problems with your period, most pills will probably work for you. But if it’s truly terrible, then a pill that prevents ovulation and minimizes the number of periods – or stops them entirely – will probably be more helpful. This is usually achieved by choosing a tablet that contains more active tablets per package than the standard 21 tablets. Some pills contain 24 active pills, while others allow you to take up to three months before you get a placebo pill and therefore bleeding. However, you don’t necessarily need special pills for this: if you talk to your doctor about it first, you can skip your period by simply skipping the placebo pills and starting a new pack. It is perfectly safe , although some women choose to have their period as proof that they are not yet pregnant.

Looking for quality information

Whether you’re looking to try a pill or switch to a new one, it’s important to base your research on solid information from trusted sources. Here are some great starting points:

Finally, if you’re unlucky with an OB/GYN, both Brandi and Davis recommend looking for a Family Planning (FP) specialist. “Family planners [have] special expertise in birth control, how it works and how to tailor it individually to the needs of the patient,” says Brandi, who is herself a family planner. “If you feel that you are not being heard by those who give you birth control pills, I recommend contacting a pregnancy planner.” Many professionals also provide online consultations via video chat.

Don’t expect too much or too little

Whenever you start a new pill, the best thing you can do is to discard any preconceived notions about the side effects it may or may not cause. It usually takes your body three to six months to fully adjust, and while you can be sure you won’t get pregnant, any other side effects will remain a mystery until you try. If that sounds disappointing, it certainly is, but here’s how Davis thinks about it: “It’s nothing special,” she says, laughing. “I mean, it’s a cure.”

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