The contraceptive Pill

When it comes to choosing contraception, many women are now turning towards the contraceptive pill, which is an oral contraceptive in pill-form.

These pills contain hormones, which act on the ovaries by prohibiting their ovulation function. If no egg is produced, then the sperm have nothing to fertilise.

There are three big types of contraceptive pill:

• The combined pill (oestrogen-progestogen) or combined pill contains two types of hormone: a synthetic progestogen and an oestrogen (Ethinyl estradiol). It has different dosages (from 15 to 50 gamma depending on the pill). This is the most-used contraceptive pill and makes up the majority of various pharmaceutical contraceptive pill supplies (see table below).
• The mini-pill (progestogen only) contains only one type of hormone, progestogen. It does not contain oestrogen. The progestogen could be either 75mg of Levonorgestrel or Desogestrel. This pill should be taken continuously, i.e. every day without a break
• Sequential contraceptive pills have a packet containing the two hormones but in different pills. The pills at the beginning of the packet only contain oestrogen. Then, from the 7^th or the 14^th pill, (it varies according to the brand), the pills become combined pills by adding progestogen. This sequence imitates the natural menstrual cycle’s hormone production.

Do not confuse the combined pill and the mini pill, which differ in both their composition and how they work.

How does the contraceptive pill affect the body and menstruation?

The combined contraceptive pill works in three ways.

1. Firstly, it acts directly on the ovaries by preventing ovulation from occurring, which usually produces one egg every month.
2. Then the hormones act directly on the uterus and its mucosa, whose role is the create a conducive ecosystem to receive the egg (which fixes itself to the uterine wall). The hormones make implantation impossible.
3. Finally, the pill acts on the reproductive mechanism, simply by stopping the sperm from entering the cervix by altering the cervical mucus so that they are prevented from moving freely.

The mini pill works in almost the same way as the combined pill, but with one modification. Whilst they also prevent egg implantation and the sperm’s entry into the cervix, they do not always stop ovulation and this varies depending on the pill.

Combined contraceptive pill or the mini-pill? Which should I take?

The main advantage of the combined pill is that it gives you shorter, lighter and less painful periods, which will occur regularly.

This is precisely where the mini-pill has some disadvantages, which principally involve disturbances to your menstruation.

The mini-pill will either stop your periods completely, will cause random spotting, or, you may still see a period every 4 weeks.

However, the mini-pill is more suitable for smokers and women who are prone to health complications (high cholesterol, diabetes, hypertension, history of embolisms, phlebitis). It is also recommended for women who have just given birth or who are breastfeeding. The sequential pill may also be prescribed in certain cases, particularly after a curettage abortion.

How do I take the contraceptive pill?

The pill can sometimes feel like more of a constraint than a way to make life easier, especially when you are taking it for the first time. However, there is no need to panic, you simply need to adopt and get used to the following rules.

The pill comes in a pack of 21 or 28 pills.

21-pill packs are for combined pills, whilst 28-pill packs can be either combined pills or mini-pills.

For a 21-pill packet:

1. Take the first contraceptive pill on the first day of your period, and remember it, as this will always be the day you start a new packet (Monday, Tuesday)
2. Take 1 pill a day at a fixed time. A reminder on your phone can be very useful if you are a forgetful person, or if you are just starting to take the pill. You should take the pill for 21 consecutive days.
3. The 22^nd day is the last day of taking the pill, and you take a 7-day break. Your period should arrive during this break.
4. On the 8^th day, you should start taking the pill again by starting a new packet (the day should be the same as the day you initially started the pill).

For a 28-pill packet:

1. The first stage remains the same
2. Take 1 pill a day at a fixed time. You will take the pill for 28 days without a break. Your period will arrive for the last 7 pills in the packet, which is placebos. This can also be useful if you are a forgetful person and a daily reminder doesn’t suffice.
3. On the 8^th day, you should start a new pack. There is no break between packets.

Advantages and disadvantages: facts and fiction

Every contraceptive pill has a shared advantage: they suit most people. You should take at least 3 months to decide whether or not a pill suits you, after which you can try another pill if side effects persist.

• The pill makes you fat

In actual fact, the pill itself does not make you fat, especially with the newer generations. However, it does increase your appetite. If you notice that you have a higher appetite when taking the pill, you can try to be stricter with your diet than normal and it should return to normal after the first 3 months. Know that if you do gain any weight from the pill, it will be minimal.

• Can you smoke while taking the pill?

This is not advised; however, it is neither impossible nor forbidden. It depends on a lot on your history, habits and age.

If you are a heavy smoker with a history of problems taking medication, you should probably opt for the mini-pill, which carries fewer risks.

If you are under 35 and have no history or problems taking medication, you should take the pill as usual but carry out consultations and assessments more regularly.

If you are over 35, you ought to change your birth control method to either a non-combined or non-hormonal contraception.

• The pill makes you depressed

Many women report feeling either slightly or seriously depressed whilst using the pill. Studies such as Depression as a side effect of the contraceptive pill, Expert Opinion on Drug Safety, July 2007 show that out of every woman claiming to be depressed, twice as many of them were using an oestrogen-progestogen hormonal contraceptive (either the pill, implant or patch).

However, it is necessary to note that the pill and oestrogen-progestogen drugs are not the only cause of depression if you already experience anxiety, stress or are already depressed before taking it.

1. It is mostly women who already have depressive tendencies who are most prone to the depressive effects of the contraceptive pill. Depressive episodes can occur in women with no previous history of depression, but this is very rare.
2. The second thing to note is that despite hormonal mood swings sometimes leading to depression, it is usually marginal but effective changes in the body that contribute to feeling depressed, such as weight gain, acne or a loss of libido.

To better understand what is happening, you need to be aware that the hormones in birth control pills interfere with other elements in your body:

Vitamin B6 is essential to our current mood. Its role is to synthesise other substances, such as serotonin and dopamine, which are neurotransmitters that impact our mood and make us “happy.” However, oestrogenic birth control pills prevent Vitamin B6 from playing its role, which leads to a B6 deficiency and a neurotransmitter imbalance and hence a decline in your mood.

To counter the depressive effects of the pill, you can increase your intake of vitamin B6. In this situation, it is appropriate and effective to consume about 50mg of vitamin B6 a day. You can find it in fish (especially salmon); meat (especially beef or lamb, with liver being particularly rich); wholegrain cereals (muesli, breakfast cereals); and wholegrain rice.

All foods that are rich in vitamin B6 may also be accompanied by increased magnesium intake. The combination of these two supplements will amplify the effects of vitamin B6 and improve its effects against depression. There are specialised magnesium-enriched waters such as Contrex and Hepar. A 200mg magnesium supplement is enough to help you avoid problems with your mood.

• The pill reduces your libido

Scientific studies on this subject vary and there is no consensus on the matter as of yet. 20 to 40% of women taking birth control pills report that they suffer from a reduction in their libido, which is caused by the pill’s effect on the production of testosterone in the ovaries, which drops to just 50%.

However, this hormone primarily effects our sexual desire.

Thus, women who usually see their libido surge in mid-cycle when not using the pill are more likely to feel the effects of a decline in testosterone.

Similarly, women who take an oestrogen-based pill (especially for treatment of acne) will also witness a significant decline in their libido since these pills directly affect testosterone production. In contrast, some women report an increase in libido because of feeling freer and less afraid of becoming pregnant.

• The contraceptive pill causes acne

This all depends on the type of progestogen and your own disposition.

For 1^st and 2^nd generation contraceptive pills, the progestogen is closer to androgen, which is responsible for male characteristics and increased acne. These are progestogen-based pills and are therefore suitable for women with a high oestrogenic profile (heavy periods, breasts that shrink and swell, heavy feeling in legs) who will not suffer from the hormone’s acne-inducing effects.

On the other hand, avoid these pills if you have high progestogen levels (prone to acne and extra hair growth). You should opt instead for an oestrogen-based pill. These mostly contain a progestogen like drospirenone. This hormone has a strong anti-androgenic effect so will help to reduce acne. Finally, progestogen mini-pills can actually cause acne if you are prone to skin problems.

• The contraceptive pill increases the risk of ovarian cancer

No, in fact, this method of contraception even minimises it. A recent study determines that 200,000 women have avoided endometrium cancer, thanks to the combined pill. The progestogen’s beneficial effect is that it prevents abnormal cell division and stops cancer from forming in the uterus. This protective effect continues after you have stopped taking the combined pill. The contraceptive pill is also prescribed to prevent ovarian cysts. It is also effective against pelvic inflammation diseases (all sexually transmitted infections that affect the reproductive system and that can, without treatment, causes infertility); symptoms associated with endometriosis (severe pain during menstruation, caused by a reflux of period blood towards the stomach); dysmenorrhea (menstrual pain felt in the lower abdomen, the origin of which is unclear); and finally reduces the risk of anaemia.

• Thrombosis

This risk does exist, but it is uncommon. This involves the worrying formation of a blood clot in your veins, artery or mouth. If this blood clot prevents blood from reaching the heart it is called ‘phlebitis’. If the clot eventually detaches itself, it is led through normal circulation until it reaches the lung, which is made up of vessels that are too small to let the clot pass through. The clot will hence plug itself and the blood can no longer circulate and feed the lungs, leading to pulmonary embolism.

The risk of thromboembolism (due to cardiovascular problems, phlebitis and pulmonary embolism) can be increased when taking the pill. However, it should be remembered that this is only a very small risk and only happens in the rarest of cases when there are no previous aggravating factors. We expand on this point further on.

Generations of the contraceptive pill.

There are 4 generations of the contraceptive pill, with the difference being the doses and types of progestogen included. It also refers to changes in time, risks and side effects.

The reason for there being successive generations of the pill is so that its side effects are reduced with each one. The first generation pills have heavier doses of oestrogen (with Norethisterone as its progestogen)

Side effects include breast tenderness, nausea and migraines, with an increased risk of vascular disorders. There is only one 1^st generation pill on the market: Ariella.

2nd generation pills contain a different progestogen (levonorgestrel) and they aimed to reduce the side effects caused by the first generation. These are still one of the most prescribed generations of pill today (Ovranette, Adepal, Qlaira, Leeloo Ge, Ge Daily).

In fact, Yasmin, Microgynon and Cerazette are sold more than any other second generation pills in UK as they often have the fewest side effects. They are all based on progestogen, so are suitable for women with dysmenorrhea, i.e. painful menstruation accompanied by menorrhagia and hypermenorrhoea, which causes heavy and long periods.

3rd generation contraceptive pills contain a synthetic progestogen (gestodene, desogestrel, norgestimate and dienogest). They significantly reduce side effects such as acne, breast pain and nausea.

Therefore, the 3rd Generation pills have a higher oestrogenic content than 2nd generation pills. They are hence suitable for women who often suffer from acne, or who have a progestogen profile. This generation includes pills such as Dianette, which is primarily an anti-acne treatment. In addition to being effective against acne, Mercilon also has the advantage of combatting endometritis.

Cerazette is defined as a third generation pill, however, it is not a combined oestrogen-progestogen pill. It is a progestogen-only pill for women who cannot tolerate oestrogen.

4th generation pills contain a new synthetic progestogen (drospirenone or chlormadinone) and are even more effective in preventing acne. They also contain a lower hormonal dose, which is particularly the case for Jasmine.  Jasmine also has a diuretic effect, which helps to reduce water retention and hypertension. Qlaria is slightly different, however, in that it contains a natural oestrogen hormone which helps to care for the uterine and vaginal ecosystem whilst also being effective against acne.

What are the risks, side effects and contraindications?

These contraceptives have been the subject of controversy, as they carry more risks and disadvantages than 2^nd generation pills, despite their effectiveness and limited side effects. 3^rd generation pills cause venous thrombosis more often than 2^nd generation pills, and according to the National Drug Safety Agency, this is the risk of contracting it depending on your pill usage:

• 5 to 1 in 10,000 for women who do not use the pill
• 2 in 10,000 for women using a 2^nd generation oestrogen-progestogen pill
• 3 to 4 in 10,000 for women using combined pills based on desogestrel or gestodene (3^rd generation) or drospirenone.

However, these statistics are comparable when we remember that the risk of contracting venous thrombosis for pregnant women is 6 in 10 000 women. What’s more, the European Commission has now imposed marketing maintenance, after the European Medicines Agency conducted a survey between 2013-2014, which concluded that, although women over 30 suffering from obesity have a higher risk, the combined contraceptive pill is the most common cause of venous thrombosis in women.

Hence no contraceptive pill avoids risk altogether, if not progestogen-only pills (containing just one hormone, known as the mini-pill). This health overhaul also strengthened usage constraints (especially for women over 30 suffering from obesity), prescription regulation and also improved information on contraindications. It is important to know that 3rd and 4th generation pills are not prescribed by doctors as a first attempt, and they will only be prescribed after having checked your risks of thrombosis depending on your genetics, family history and social habits.

To summarise, birth control pills of every generation carry some risk of thrombosis because they stimulate blood clots. The risk is doubled for 3rd and 4th generation pills. It is, therefore, necessary to eliminate some risk factors and respect contraindications.

These risks are ordered according to vascular incident (cerebral, pulmonary)

In addition, certain lifestyles and circumstances are risk factors that are incompatible with this method of contraception and therefore require increased monitoring:

• Age
• Smoking
• Obesity
• Diabetes and acute glycaemic levels (fats and carbohydrates)
• Taking other drugs (sleeping pills and barbiturates, rifampicin and antiepileptic, griseofulvin to treat fungal infections of hair, nails and skin; certain anticonvulsants, certain anti-asthma drugs and other drugs for tuberculosis.) This is not an exhaustive list, so be sure to talk with your doctor if you take any other long-term treatment.

Your doctor must, therefore, carry out a medical examination and check your risk of thrombosis or any other health factor before directing you towards a 3^rd or 4^th generation pill. Furthermore, by being aware of the symptoms of thrombosis, you can prevent it from getting worse.

Finally, regardless of what generation pill you are taking, you must also carry out regular medical and gynaecological follow-ups so that you can identify any risks (breast and uterine examinations, blood pressure monitoring, metabolic examination of your lipid and carbohydrate levels).

Is the contraceptive pill effective?

Quite simply, yes.

Obviously, the pill is objectively effective due to its fabrication, composition and how the pill itself works. But, its effectiveness also depends on user habits. It is essential to obey the rules concerning administration and to take the pill regularly at a certain time without repeatedly forgetting a pill. The pill is also effective from the moment you take the first one (providing you take it at the right time) and continues to be so for the whole cycle, even during the break.

You can base the pill’s effectiveness on its statistical data based on the number of women who fall pregnant while using the pill under perfect conditions. Based on this information, the pill is 99% effective.

As for its effectiveness in real conditions, and taking oversights and mistakes into account, its effectiveness remains very high at 96% for the combined pill, and 99% for the progestogen-only pill.

What do I do if I forget a pill?

It can happen that you forget your pill. Working a lot, an unforeseen event, not being able to get home on time, or simply because you swapped your bag over in the morning, there are numerous reasons that you might forget your pill! Depending on the pill that you take, you need to act quickly. What you should do depends on whether you take a progestogen-only pill, a combined pill, whether it is 21 or 28 pills, how many placebo pills there are, etc.

If you take a combined pill

• If you remember within 12 hours, take the pill as soon as you remember and continue taking the pill as usual until the end of the packet. There is no need to worry as you remain protected from pregnancy.
• If you remember after 12 hours, take the pill as soon as you remember. Continue to take the next pill as usual. However, you are not immediately protected from pregnancy so there are various procedures to consider, depending on the case:
• If you have had sex in the previous 5 days, take the morning after pill
• If you have sex during the next 7 days after forgetting your pill, use a condom in addition to your contraceptive pill.

There are other possibilities to consider when taking the pill, especially if you are sick whilst taking it. If you experience diarrhoea or vomiting within 4 hours of taking the pill, it may be possible that the pill was not absorbed properly. You should, therefore, take another pill immediately.

If you take a mini-pill there is a smaller range of tolerance. You should take the same directions as above, but apply them to a shorter time period, of 3 hours, rather than 12.

Medical review on March 10, 2017 by Dr. Davis Taylor