Birth Control Pills & Patch
The following page includes commonly asked questions and guidance about how to use your birth control medication.
What is birth control used for?
Preventing pregnancy - the most common reason for birth control is to prevent pregnancy. Birth control pills work in many ways, but the most important way is to send a signal to your brain not to release an egg.
Menstrual Pain - Birth control pills can be used for managing menstrual and mid-cycle pain. In some women with a diagnosis of endometriosis or chronic pelvic pain, birth control pills can be used continuously (i.e. skipping the hormone pills) and is often a better way to control pain symptoms than having a monthly bleed.
Acne and Hair Growth - Birth control pills help with suppressing male hormones that are responsible for acne and hair growth in women (i.e. facial hair growth). In some conditions like PCOS (polycystic ovarian syndrome), birth control is an effective way to improve acne, regulate cycles and prevent unnecessary hair growth.
What are the types of birth control available?
Estrogen/Progesterone (COC)
Theoretical Effectiveness in Preventing Pregnancy: 99.7%
Real World Effectiveness in Preventing Pregnancy: 91%
How to use: Take a pill daily for 21 or 24 pills, followed by 4 or 7 hormone-free pills (depending on the brand) that triggers a bleed
Benefits: Decreases menstrual cramps, makes menstrual periods lighter, more regular and less painful, decreases acne
Disadvantages: Have to remember to take a pill daily, not all women can use birth control pills containing estrogen due to stroke risk, slightly higher risk of blood clots, also has a risk of nausea, bloating and headaches
Progesterone Only Pill
Theoretical Effectiveness in Preventing Pregnancy: 99.7%
Real World Effectiveness in Preventing Pregnancy: 91%
How to use: Take a pill daily
Benefits: Reduce blood loss and helps women with anemia
Disadvantages: Have to remember to take a pill daily, have to take pill within the same 3 hours or high failure rate
IUD (hormone) (inserted every 3-5 years)
Theoretical Effectiveness in Preventing Pregnancy: 99.8%
Real World Effectiveness in Preventing Pregnancy: 99.8%
How to use: Inserted by a family doctor or OBGYN
Benefits: may cause very light or no periods, comfortable - you and your partner should not feel the IUD
Disadvantages: may have unscheduled bleeding or spotting, may trigger headaches in a small group of people, may cause weight gain
IUD (copper) (Inserted every 3-5 years)
Theoretical Effectiveness in Preventing Pregnancy: 99.4%
Real World Effectiveness in Preventing Pregnancy: 99.2%
How to use: Inserted by a family doctor or OBGYN
Benefits: comfortable - you and your partner should not feel the IUD
Disadvantages: may cause heavier periods
Depo-Provera Injection (given every 11-13 weeks)
Theoretical Effectiveness in Preventing Pregnancy: 99.8%
Real World Effectiveness in Preventing Pregnancy: 94%
How to use: Injected every 11-13 weeks by a health care provider
Benefits: May cause very light or no periods
Disadvantages: May have side effects such as weight gain
Evra Patch (Skin Patch)
Theoretical Effectiveness in Preventing Pregnancy: 99.7%
Real World Effectiveness in Preventing Pregnancy: 91%
How to use: Use the patch on the skin for a patch, then replace it weekly for a patch-free week. The 4th week is patch-free to allow for a bleed.
Benefits: Decreases menstrual cramps; makes menstrual periods lighter, more regular and less painful; decreases acne
Disadvantages: Slightly higher risk of blood clots - also has a risk of nausea, bloating and headaches
Nuva Ring (Vaginal Ring)
Theoretical Effectiveness in Preventing Pregnancy: 99.7%
Real World Effectiveness in Preventing Pregnancy: 91%
How to use: Ring is inserted into the vagina and left in place for 21 days; the ring is removed for 7 days to allow a bleed before another one is inserted
Benefits: Decreases menstrual cramps; makes menstrual periods lighter, more regular and less painful; decreases acne
Disadvantages: Slightly higher risk of blood clots - also has a risk of nausea, bloating and headaches
Nexplanon (Arm implant)
Theoretical Effectiveness in Preventing Pregnancy: 99.95%
Real World Effectiveness in Preventing Pregnancy: 99.95%
How to use: Implant is inserted in the inner upper arm, and is inserted for up to 3 years.
Benefits: May cause very light or no periods
Disadvantages: Requires a surgical procedure
Male Condom
Theoretical Effectiveness in Preventing Pregnancy: 98%
Real World Effectiveness in Preventing Pregnancy: 82%
How to use: New condom is used with each episode of intercourse
Benefits: Protects against STIs
Disadvantages: Some people have latex allergies
Female Condom
Theoretical Effectiveness in Preventing Pregnancy: 94%
Real World Effectiveness in Preventing Pregnancy: 88%
How to use: New condom is used with each episode of intercourse
Benefits: Protects against STIs
Disadvantages: Some people have latex allergies
Male Vasectomy
Theoretical Effectiveness in Preventing Pregnancy: 99.9%
Real World Effectiveness in Preventing Pregnancy: 99.5%
How to use: Surgery completed by a urologist or family doctor
Benefits: No further prevention is required to protect against pregnancy
Disadvantages: Requires surgery which is typically permanent (rarely reversed successfully)
Female Tubal Ligation (i.e. “Tubes Tied”)
Theoretical Effectiveness in Preventing Pregnancy: 99.5%
Real World Effectiveness in Preventing Pregnancy: 99.5%
How to use: Surgery completed by an OBGYN.
Benefits: No further prevention is required to protect against pregnancy
Disadvantages: Requires surgery which is typically permanent (rarely reversed successfully)
Withdrawal Method (“Pull Out”)
Theoretical Effectiveness in Preventing Pregnancy: 96%
Real World Effectiveness in Preventing Pregnancy: 78%
How to use: Male withdraws before ejaculation (high failure rate)
Benefits: No cost
Disadvantages: Not very effective, may decrease sexual pleasure for both partners
What hormones are in birth control?
Nearly all birth control pills contain two hormones - estrogen and progesterone - two hormones your body naturally produces. These pills are called Combined Oral Contraceptives (COCs). One type of birth control, called Micronor, is a progesterone-only pill.
Birth Control Pill
What are the different types of birth control pills?
Most birth control pills are mono-phasic - that means a single dose of estrogen and progesterone in all the hormone pills in the package. Nearly all birth control pills prescribed by doctors are mono-phasic pills.
Some pills are multi-phasic - that means the hormone strength in each package changes from one week to the next. Most of the time, it is the progesterone dose that is changed (i.e. Linessa, Tri-Cyclin, Tri-Cyclin Lo) but in other cases it is the estrogen pill (i.e. Triquilar). Multi-phasic pills were originally developed to reduce hormonal side effects including irregular bleeding, but to date, there is no evidence that they are different than monophonic pills.
How does the birth control pill work?
The birth control pill prevents the ovaries from releasing an egg each month (ovulation). It also changes the lining of the uterus, making it difficult for an egg to attach. Additionally, it alters the cervical mucus, making it harder for sperm to enter the uterus.
How do I use the birth control pill?
Start taking the pill on the first day of your period or the Sunday following the first day. Take it at the same time every day to maintain effectiveness. You can align it with a daily routine like breakfast or a shower.
- 28-day packs: Take one pill daily for 28 days. The first 21 pills contain hormones, and the last 7 are inactive. Your period should start during the inactive pills. Begin a new pack after finishing the previous one, even if your period is ongoing.
- 21-day packs: Take one pill daily for 21 days, then stop for 7 days. Your period should start during this break. Begin a new pack after the 7-day break, even if your period is ongoing.
When should I stop taking birth control pill?
Birth control pills are considered generally safe until the age of 50 in non-smoking women. Most health care providers will stop birth control at the age of 50.
How do I start birth control?
1st day of your menstrual cycle
Start the package on the 1st day of your cycle. Back-up birth control (i.e. condoms) is not required.
After miscarriage or abortion
Start within 7 days, and use backup birth control for 7 days (i.e. condoms) to reduce pregnancy risk.
Start the day the prescription is given
Start the pills right away. If it has been more than 5 days since the 1st day of your last menstrual cycle, use a back-up birth control (i.e. condoms) for the 1st 7 days on the pills.
Complete a pregnancy test 2 weeks into the pill package.
Start on Sunday
Start the pills on the 1st Sunday after your period begins. Doing so avoids bleeding on weekends. If it has been more than 5 days since the 1st day of your last menstrual cycle, use a back-up birth control (i.e. condoms) for the 1st 7 days on the pills.
Complete a pregnancy test 2 weeks into the pill package.
What should I do if I miss pills?
Miss One Pill
If you miss a pill anywhere in your cycle, please take a pill right away and continue taking your other pills daily. If you notice you missed a pill the day after skipping one, take 2 pills on that day.
Miss Two Pills
If you miss two or more pills, take one of the missed pills when you remember (this might mean taking 2 pills on the day you remember). For example, if you missed 3 pills, you would take 1 extra pill on the day you remember, and would resume your regular pattern of one pill daily. You would not need to take the 2 other missed pills.
Miss Two Pills in 1st Week
If you missed 2 pills in the 1st week of your package, AND you had unprotected sex, we recommend you discuss emergency contraception with your pharmacist.
Miss Two Pills in 3rd Week
If you miss 2 or more pills in the 3rd week of your package (day 15-21), skip the sugar pill week and start a new package.
Combined Oral Contraceptives (COCs)
What are Combined Oral Contraceptives (COCs)?
Combined oral contraceptives (COCs) are birth control pills that contain both estrogen and progesterone. All birth control pills contain generally the same estrogen (ethinyl estradiol) but have different progesterones (i.e. cyproterone, desogestrel, drospirenone, levonorgestrel, norethindrone). The strength of the estrogen, and the type of progesterone vary between pills.
Is Micronor or the Mini Pill a COC?
Micronor, or the ‘mini pill’ is not a combined hormonal contraceptive as it has only one hormone, progesterone. It does not contain any estrogen.
What are the benefits of COCs?
Aside from pregnancy prevention, regulating menstrual cycles and reducing flow associated with menstrual cycles, COCs have a number of other benefits. These include but are not limited to:
Reduce undesirable hair growth
Improvement in acne
Reduce lifetime risk of endometrial cancer
Reduce lifetime risk of ovarian cancer
Reduce lifetime risk of colorectal cancer
Reduce the formation of new ovarian cysts
Help with symptoms of pre-menstrual dysphoric disorder
Help with endometriosis pain
What are the risks with estrogen?
Estrogen carries a number of risks for individuals with specific medical conditions. If you do not have a listed medical condition below, birth control pills are generally very safe.
Hormonal contraception containing estrogen carries a slightly higher risk of developing blood clots in your legs, arms, lungs or brain. This risk is approximately 3x what it is for someone not on hormonal contraception, but the total or absolute risk is very low (3-15 women in 10,000 will get a blood clot after 1 year on birth control). This risk is greatest in the 1st year of contraception and declines over time. The risk is less than for someone who is pregnant.
Do COC’s have long-term effects on my fertility?
No. Return to your age-specific fertility occurs typically no later than 90 days after stopping birth control. The pregnancy rate for women who stop using birth control matches those who have never been on birth control after they have stopped birth control. Remember, your fertility rate drops significantly after age 35, so talk with a health care provider about managing your fertility after or before this age.
Who should not be on COC birth control?
People with the following medical conditions should not be on COCs (i.e. pills with estrogen):
Have a history of breast cancer
< 42 days postpartum (i.e. first 42 days after having a baby)
Liver cirrhosis
History of Deep Vein Thrombosis or Pulmonary Embolus (blood clots in veins or lungs)
Recent surgery requiring you to be bed-bound
Diabetes for more than 20 years
Diabetes for less than 20 years with kidney, eye or nerve damage
Symptomatic gallstones
Migraines with auras (aura = neurological symptoms like vision changes, muscle weakness, numbness, etc)
Some people who have had bariatric surgery
High blood pressure or are on high blood pressure pills
Heart Disease (i.e. have plaque in your arteries, or had stunting or a cardiac bypass)
Have a predisposition to blood clots (AT Deficiency, Protein C or S deficiency, Factor V Leiden, Prothrombin mutation)
Hepatocellular adenoma
Liver Cancer
Have multiple risk factors for heart disease (i.e. high cholesterol, smoking, older age)
Multiple Sclerosis specifically with reduced mobility
Cardiomyopathy
Smoking and over 35
Some people who had had a solid organ transplant
Have had superficial venous thrombosis
Lupus
Heart valve disease
Some antibiotics (rifampin)
Take seizures medications (lamotrigine, phenytoin, carbamazepine, topiramate, oxcarbazepine)
On some antivirals used for PrEP (foamprenavir)
What happens if I wait before starting my next birth control package?
If you are on combined contraceptive pills and your packages contain placebo pills, delaying starting your package when your current package finishes increases your chance of pregnancy.
Do birth control pills increase my risk of blood clots?
Yes, combined oral contraceptives (estrogen-progesterone pills) increase your risk of blood clots by 3-4x compared to women who do not use hormonal birth control pills. The risk of blood clots is greatest in the 1st year of birth control. Pregnancy, by contrast, carries a higher risk of blood clots of approximately 4-5x. The rate is quite low, however.
Progesterone-only pill
Who should be on a progesterone-only pill?
Women who cannot take COCs should be on a progestin-only pill.
Women who don’t want estrogen exposure
Who should not be on a progesterone-only pill?
History of breast cancer
Liver Cirrhosis
Some types of bariatric surgery
Hepatocellular Adenoma
Liver Cancer
Heart disease
Prior stroke or mini-stroke (TIA)
Lupus
Some antibiotics (rifampin)
Take seizures medications (lamotrigine, phenytoin, carbamazepine, topiramate, oxcarbazepine)
Does birth control increase my risk of cancer?
Birth control has actually been demonstrated to reduce the risk of ovarian and endometrial cancer. It does not cause breast cancer, but we do not use birth control in women with a breast cancer history because estrogen can ‘feed’ some types of breast cancer. Taking oral contraceptives does not increase your chance of breast cancer whatsoever. There is a small increase for cervical cancer, which declines after you stop birth control.
How many pills are hormone pills in a package?
Most pill packages come in a 28-day format. Typically, 21 of the pills are hormone pills, and 7 of the pills are placebo (sugar) pills. Many hormone pills now come in a 24/4 package (24 hormone pills, 4 ‘sugar’ pills). Pharmacies also offer pills in a 21-day formats (no sugar pills).
What is the benefit of a higher estrogen or a 21-day brand vs. A 24-day brand?
Higher estrogen doses and 21-day pill packages have lower rates of breakthrough or irregular bleeding. Not all women experience this side effect, so if you are not experiencing breakthrough bleeding, there is no need to change birth control brands.
Migraines and Combined Hormonal Contraceptives
What's the definition of a migraine?
It is a 'recurrent headache disorder manifesting in attacks lasting 4-72 hours.' And it requires:
At least 5 attacks
Has two of the following four characteristics
One-sided
Pulsatile quality
Moderate or Severe Pain
Worse with routine activity (climbing stairs)
During the headache, you have either/both:
Nausea and/or Vomiting
Light sensitivity and Sound Sensitivity
What is a migraine with aura?
You experience visual, sensory and/or speech/language symptoms.
Examples of aural symptoms include:
Vision: vision loss (spot or shape), may involve a quarter, half or entire visual space
Sensory: tingling, numbness or pain
Motor: weakness in a muscle group (face, eyes, arms/legs)
Language: difficulties finding words or articulating
To qualify as an aura, you have to have 2 of the following 4 characteristics
1 aural symptom, spreading gradually over 5 minutes, or 2 or more symptoms in succession
Each aural symptom lasts 5-60 minutes
Headache starts within 60 minutes of an aura
At least one of the aural symptoms is on 1 side of your body
What is not an aura?
Blurring, floaters or flashes lasting a few seconds before or during a migraine do not meet our medical criteria for an aura.
Why are migraines with aura relevant to combined hormonal contraception (COC, estrogen-containing) birth control?
Women with migraines are at a 2-4 x increased risk of stroke on combined hormonal contraception. The risk is higher in women with aura, so current guidelines dictate that COCs should not be prescribed to women with migraine headaches of the aural subtype.
EVRA® Transdermal Patch
What is EVRA®?
EVRA® is a birth control patch that you stick on your skin. It releases hormones (norelgestromin and ethinyl estradiol) that help prevent pregnancy.
How does EVRA® work?
EVRA® releases hormones through your skin into your bloodstream. These hormones prevent ovulation (release of an egg) and make it harder for sperm to reach an egg or for an egg to attach to the womb.
How do I use EVRA®?
Start: Apply the first patch on the first day of your period or the first Sunday after your period starts.
Weekly: Wear the patch for 7 days, then replace it with a new one on the same day each week (Patch Change Day).
Cycle: Do this for three weeks. In the fourth week, do not wear a patch. You should have your period during this week.
Where do I place the patch?
Place the patch on clean, dry skin on your buttock, abdomen, upper outer arm, or upper torso (not on your breasts). Avoid areas that are red, irritated, or cut.
What if my patch falls off?
If it’s off for less than a day, try to reapply it or use a new one immediately. Continue as usual.
If it’s off for more than a day, start a new cycle with a new patch and use backup contraception (like condoms) for the first week of the new cycle.
What are the side effects of EVRA® ?
Common side effects include nausea, headache, breast discomfort, and skin irritation where the patch is applied. Serious side effects are rare but can include blood clots, stroke, and heart attack.
Who should not use EVRA®?
Do not use EVRA® if you:
Have a history of blood clots, stroke, or certain heart conditions.
Have liver disease or certain types of cancer.
Are pregnant or suspect you might be.
Are over 35 and smoke.
Can I use EVRA® while breastfeeding?
EVRA® can pass hormones into breast milk and may reduce milk production. It’s best to use other forms of contraception until you have stopped breastfeeding.
What should I do if I forget to change my patch?
Week 1: Apply a new patch as soon as you remember. Use backup contraception for 7 days.
Week 2 or 3: If it’s been less than 48 hours, apply a new patch immediately. If more than 48 hours, start a new cycle with a new patch and use backup contraception for 7 days.
Week 4: If you forget to remove it, just remove it when you remember and start the next cycle on the usual Patch Change Day.
How should I store EVRA®?
Store EVRA® at room temperature (15-25°C). Keep it in its original packaging until you’re ready to use it. Dispose of used patches properly by folding them in half with the sticky sides together and throwing them in the garbage.
Does EVRA® protect against STIs?
No, EVRA® does not protect against sexually transmitted infections (STIs). Use condoms to protect against STIs.
What if I want to switch from another birth control method to EVRA®?
From pills: Start EVRA® on the first day of your withdrawal bleeding.
After childbirth: Wait at least 4 weeks if you’re not breastfeeding.
After abortion/miscarriage: Start immediately or wait until your next period.
Common questions
I don’t want a contraceptive which affects my hormones. Will a hormone IUD affect my whole body?
Hormonal IUDs (Mirena, Kyleena) do not have whole-body effects. For example, birth control pills exert a contraceptive effect by suppressing ovulation at the level of the brain. IUDs work by affecting the lining of the uterus and do not suppress ovulation at the level of the brain. Hormonal IUDs are a great choice for women who desire lighter or absent menstrual flow and want to avoid the systemic (‘whole body’) effects of hormonal birth control pills or depo-proverb injection.
What should I do if I have breast tenderness?
Take your pills at bedtime
Do a home pregnancy test
Talk with your doctor about changing your pill to one with a lower estrogen dose and progesterone
Talk with your doctor about trying a birth control pill with a progesterone called drospirenone
Is it safe to use birth control indefinitely?
Most people can safely use hormonal contraceptives for many years, provided their doctor has recommended it. However, long-term use of birth control containing hormones can cause issues depending on a person's medical history, age, and overall health. If you experience side effects, you can switch to a different method until you find one that works for you.
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