The first birth control pill was FDA approved in 1960 and a lot has progressed and changed in the 60+ years since then. But with more options and more information comes more questions – so here’s my list of the top 9 BIRTH CONTROL PILLS FAQs I get asked and how I respond.
First and foremost, what’s in them?
The pill is a combination of 2 hormones – estrogen and progesterone. These hormones are synthetic, not naturally occurring. The estrogen is usually called ethinyl estradiol. There are many types of progestins (the synthetic type of progesterone) – some of the more common types are levonorgestrel and drospirenone.
In birth control pills, one pill of estrogen / progesterone is taken every day. There are typically 21 to 24 days of hormonal pills in each pack. Then there are 4-7 days of placebo pills. These pills have no hormones – they are sugar pills to keep you in the habit of taking a pill every day.
Also know that birth control pills contain the same hormones and work the same way as the birth control patch (Ortho Evra and Xulane) and birth control ring (NuvaRing and Annovera). The difference is the way the delivery mode of the hormones. With the pill, you swallow one pill every day, around the same time is preferable. The patch is a small sticky patch applied to the skin and changed once a week. The hormones are absorbed through the skin into your blood stream. The ring is inserted into the vagina and hormones are released and absorbed from there. The NuvaRing is changed every 3 weeks and Annovera is meant to stay in the vagina all the time.
What’s the difference between low dose and high dose pills?
The “dose” is referring to the amount of estrogen. That very first birth control pill, Enovid, was considered “high dose” – it contained the equivalent of 50 micrograms of synthetic estrogen. That does isn’t even available on the market today! Today, only lowest, low, and moderate doses are available. Moderate is considered about 30 to 35 micrograms, Low is 20 to 30 micrograms, and lowest is less than 20 micrograms. All the doses prevent ovulation, but different doses help trouble shoot different side effects of the pill. For example, if someone has breakthrough spotting or bleeding on a low dose pill, this often improves with a moderate dose pill.
Types of progesterone – what’s the difference?
In terms of progesterone, there are different types found in birth control. They are divided into “generations” – first, second, third, and fourth generations. The third and fourth generations tend to have a more anti-testosterone component to them, so may be better at treating acne or excess dark hair growth. Your doctor can help you choose the best combination for you, depending on what your goals are and your experience with other types of birth control.
My whole point here is that there are hundreds of different combinations of birth control pills available and switching the pill may help improve any side effect you’re not happy with!
Do I ovulate on the pill?
Nope! That’s how it works as a contraception. No ovulation = no pregnancy.
This is why it’s effective, but also why it’s not effective if not taken the right way. Unplanned pregnancy while on birth control pills is usually caused by user error, not pill error!
What if my period goes away?
It’s fine! A lighter period – sometimes so light it’s barely there – is one of the benefits of the pill.
Isn’t it bad to NOT have a period?
I use the menstrual cycle, including the period, as a sort of vital sign for females of reproductive age. For people not using hormonal contraception the answer is yes, a missed / delayed / absent period is something that needs evaluation. It is often caused by a missed / delayed / absent ovulation. Remember the menstrual cycle? The first half is estrogen dominant and the second half is progesterone dominant. Ovulation is in the middle and helps these 2 hormones balance each other out. If ovulation doesn’t occur, the second half of the cycle (progesterone) is not started, so it doesn’t balance out the first half of the cycle (estrogen). That’s what people mean when they say a cycle is “estrogen-dominant” – they’re usually saying that ovulation didn’t occur!
A naturally occurring period happens when both the estrogen and progesterone drop suddenly. This causes a “withdrawal” of the hormones on the endometrial lining. The lining sheds, which is a period, and then the cycle starts over again.
What’s the difference with birth control pills? They suppress ovulation on purpose! They offer a daily balance of estrogen and progesterone, so the balance is there throughout the cycle. The period on birth control pills is not the result of natural hormonal cycling – it’s the result of stopping the hormonal pill. This drop of hormones is meant to mimic the normal functioning of the menstrual cycle and causes a withdrawal bleed.
So what if I don’t have that withdrawal bleed?
On birth control pills, it’s absolutely safe and normal to not have a withdrawal bleed. Sometimes the lining of the uterus is so thinned out that there’s nothing there to come out. It’s also possible to not have a withdrawal bleed. You can stop a period temporarily by not taking the placebo pills and just continuing on a hormonal pill every day. The way you do this: when it’s time for the placebo pills, instead of taking the placebo pills, start the next pack instead.
This works best with monophasic pills – this kind of pill has the same dose and combination of hormones every day. This is in comparison to bi- or tri-phasic pills that have either 2 or 3 combinations throughout the pill pack.
What about mood symptoms and mental health concerns?
Data does not universally support that birth control pills affect mood symptoms, but it is hard to study these types of correlations and the data is not robust.
Some studies show that some females do have an increase in mood symptoms such as anxiety and depression-like symptoms while others have an improvement in mood. Confusing, right?
One study showed that people on birth control pills have more “mind wandering” which is also a symptom associated with depression and anxiety.
On the other hand, birth control pills are often used for treatment of mood symptoms for women with PMS and PMDD and can be quite effective. There are also studies that show females who are counseled about possible side effects of the pill are less likely to stop it due to negative mood symptoms.
All that being said, if a patient of mine reports mood symptoms with the pill, we discuss alternative options – either a different combination of the pill or a difference method altogether.
Will it affect fertility?
Nope! This is extensively studied, and it appears that fertility goes back to its baseline once pills are stopped.
But … birth control pills can cover up underlying irregular periods and irregular periods themselves can affect fertility. It may also take a few months for your body to start “talking” to itself again – I typically give patients 2-3 months for a spontaneous period to come
For all these reasons, I typically offer this to patients who are stopping birth control to try to get pregnant:
- Stop about 3-6 months before planning on trying to conceive.
- In that time, use something non-hormonal for contraception, like condoms (remember, rhythm method won’t be accurate at this time. We don’t know what your natural cycle is like yet!)
- Expect a spontaneous period (not the withdrawal bleed from your pill pack) to occur about 4-8 weeks after stopping. If it doesn’t, I recommend an appointment / evaluation to my patients.
- Start taking a prenatal vitamin when you stop the pill!
I am a board certified OBGYN at Cedars Sinai in Los Angeles.
I am co-founder of Female Health Education, a platform offering digital courses, striving to empower females through health education.
My passion is promoting and demystifying health information to the public. My blog, Dr. Sara Twogood’s LadyParts Blog, provides comprehensive information about fertility, pregnancy, and gynecology topics. I am on the medical board for the period tracker app Flo; contribute as a medical expert for pregnancy app and website The Bump; and serve on the Byrdie Beauty and Wellness Review Board (Byrdie.com). I have been featured as an expert for the podcasts The Dream and Her body, Her Story and quoted in numerous online and print publications.
I am honored to be named “Top Doctor” in Los Angeles magazine for years.