Hormonal Methods of Contraception

Before starting oral contraceptives, a woman must see a doctor. Doctors ask the woman about her medical, social, and family history to determine whether she has any health problems that would make taking these contraceptives risky for her. They measure her blood pressure. If it is high, combination oral contraceptives (estrogen plus a progestin) should not be prescribed. A pregnancy test may be done to rule out pregnancy. Doctors also often do a physical examination, although this examination is not necessary before a woman starts taking oral contraceptives. Three months after starting oral contraceptives, the woman should have another examination to determine whether her blood pressure has changed. If it has not, she should then have an examination once a year. Oral contraceptives can be prescribed for 13 months at a time.

Women can start taking oral contraceptives at any time of month. However, if they start taking them more than 5 days after the first day of their period, they should use a backup contraceptive method for the next 7 days in addition to taking the oral contraceptive.

When women can start taking combination oral contraceptives after pregnancy varies:

Women with risk factors for blood clots should wait because blood clots are more likely to develop during pregnancy and after delivery. Taking combination oral contraceptives also makes blood clots more likely to develop.

Progestin-only oral contraceptives may be taken immediately after the delivery of a baby.

In most women who have recently given birth and are exclusively breastfeeding and who have not had a menstrual period, pregnancy is unlikely to occur for 6 months after the baby is delivered, even when no contraception is used. However, starting to use contraception within 3 months after delivery is usually recommended.

If a woman has coronary artery disease Overview of Coronary Artery Disease (CAD) Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more or diabetes Diabetes Mellitus (DM) Diabetes mellitus is a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be abnormally high. Urination and thirst are... read more or has risk factors for them (such as a close relative with either disorder), a blood test is usually done to measure levels of cholesterol, other fats (lipids), and sugar (glucose) before a combination contraceptive is prescribed. Even if these levels are abnormal, doctors may still prescribe a low-dose estrogen combination contraceptive. However, they periodically do blood tests to monitor the woman’s lipid and sugar levels. Women with diabetes can usually take combination oral contraceptives unless diabetes has damaged blood vessels or they have had diabetes for more than 20 years.

If women have had a liver disorder, doctors do tests to evaluate how well the liver is functioning. If results are normal, women can take oral contraceptives.

Also before starting oral contraceptives, a woman should talk with her doctor about the advantages and disadvantages of oral contraceptives for her situation.

The main advantage of oral contraceptives (birth control pills) is reliable, continuous contraception if the pills are taken as instructed.

Also, taking oral contraceptives reduces the occurrence of the following:

The risk of developing cancer of the uterus and cancer of the ovaries is reduced for at least 20 years after the contraceptives are stopped. Oral contraceptives reduce the risk of cancer of the uterus Cancer of the Uterus The most common type of cancer of the uterus develops in the lining of the uterus (endometrium) and is called endometrial cancer. Endometrial cancer usually affects women after menopause. It... read more by 60% after at least 10 years of use and cancer of the ovaries Ovarian Cancer, Fallopian Tube Cancer, and Peritoneal Cancer Ovarian cancer is cancer of the ovaries. It is related to fallopian tube cancer, which develops in the tubes that lead from the ovaries to the uterus, and peritoneal cancer, which is cancer... read more by about 50% after taking them for 5 years and by 80% after taking them for 10 years or more.

Oral contraceptives taken early in a pregnancy do not harm the fetus. However, they should be stopped as soon as the woman realizes she is pregnant. Oral contraceptives do not have any long-term effects on fertility, although a woman may not release an egg (ovulate) for a few months after stopping the drugs.

Disadvantages of oral contraceptives (birth control pills) may include bothersome side effects.

Breakthrough bleeding is common during the first few months of oral contraceptive use, particularly if women forget to take the tablets, but it usually stops as the body adjusts to the hormones. Breakthrough bleeding is bleeding that occurs between periods, when women are taking the active pill. If breakthrough bleeding persists, doctors may increase the dose of estrogen.

Some side effects are related to the estrogen in the tablet. They may include nausea, bloating, fluid retention, an increase in blood pressure, breast tenderness, and migraine headaches. Others, such as acne and changes in appetite and mood, are related mostly to the type or dose of the progestin. Some women who take oral contraceptives gain 3 to 5 pounds because they retain fluid or because appetite increases. Many of these side effects are uncommon with the low-dose tablets.

Oral contraceptives can also cause vomiting, headaches, depression, and problems sleeping.

In some women, oral contraceptives cause dark patches (melasma) on the face, similar to those that may occur during pregnancy. Exposure to the sun darkens the patches even more. If dark patches develop, doctors usually stop the oral contraceptives. The patches slowly fade after the contraceptives are stopped.

Taking oral contraceptives increases the risk of developing some disorders.

The risk of developing blood clots in veins Deep Vein Thrombosis (DVT) Deep vein thrombosis is the formation of blood clots (thrombi) in the deep veins, usually in the legs. Blood clots may form in veins if the vein is injured, a disorder causes the blood to clot... read more may be 2 to 4 times higher for women who are taking combination oral contraceptives than it was before they started taking the contraceptives. If women have a disorder that causes blood clots or have family members who have had blood clots, further evaluation is needed. These women may not be able take oral contraceptives that contain estrogen. If a woman who is taking oral contraceptives develops swelling in one leg, chest pain, or shortness of breath, they should see a doctor immediately. If doctors suspect that a woman taking oral contraceptives has deep vein thrombosis Deep Vein Thrombosis (DVT) Deep vein thrombosis is the formation of blood clots (thrombi) in the deep veins, usually in the legs. Blood clots may form in veins if the vein is injured, a disorder causes the blood to clot... read more (a blood clot, usually in the leg) or pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism is the blocking of an artery of the lung (pulmonary artery) by a collection of solid material brought through the bloodstream (embolus)—usually a blood clot (thrombus) or... read more (a blood clot in the lungs), the contraceptives are stopped immediately. Tests are then done to confirm or rule out the diagnosis.

Surgery increases the risk of blood clots, so women should stop taking oral contraceptives before a surgical procedure. They should ask their doctor when to stop and restart the contraceptive pills. Limited movement (immobility) due to an injury or travel also increases the risk of blood clots. Thus, if a woman's movements are limited, she may need to try to move around as much as possible or take other measures to prevent blood clots from developing. For example, women can elevate their legs, flex and extend their ankles about 10 times every 30 minutes, and/or walk and stretch every 2 hours while traveling.

Cervical cancer Cervical Cancer Cervical cancer develops in the cervix (the lower part of the uterus). Most cervical cancers are caused by human papillomavirus (HPV) infection. Cervical cancer usually results from infection... read more is slightly more likely to develop in women who use oral contraceptives for more than 5 years. But 10 years after stopping use, this risk decreases to what it was before starting oral contraceptives. Also, whether the increased risk is related to the oral contraceptives is unclear. Women who are taking oral contraceptives should have Papanicolaou (Pap) tests Screening for Cervical Cancer Sometimes doctors recommend screening tests, which are tests that are done to look for disorders in people who have no symptoms. If women have symptoms related to the reproductive system (gynecologic... read more as recommended by their doctor. Such tests can detect precancerous changes in the cervix early—before they lead to cancer.

If women developed jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more due to reduced or slow movement of bile through the bile ducts (cholestasis Cholestasis Cholestasis is reduction or stoppage of bile flow. Bile is the digestive fluid produced by the liver. Disorders of the liver, bile duct, or pancreas can cause cholestasis. The skin and whites... read more ) during a previous pregnancy, they may have the same problem when they take oral contraceptives. They may still be able to take oral contraceptives, but they should have regular examinations and blood tests to check for this problem. However, if women developed jaundice when they took oral contraceptives in the past, they should not take them again.

Gallstones Gallstones Gallstones are collections of solid material (predominantly crystals of cholesterol) in the gallbladder. The liver can secrete too much cholesterol, which is carried with bile to the gallbladder... read more are not more likely to form in women who take low-dose oral contraceptives.

The risk of having a heart attack Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount... read more is increased if women who are older than 35 and who smoke take oral contraceptives. Typically, such women should not use oral contraceptives.

If women have a high triglyceride (a fat) level Dyslipidemia Dyslipidemia is a high level of lipids (cholesterol, triglycerides, or both) or a low high-density lipoprotein (HDL) cholesterol level. Lifestyle, genetics, disorders (such as low thyroid hormone... read more , taking combination oral contraceptives can increase the level even more. A high triglyceride level may increase the risk of a heart attack or stroke in people who have other risk factors for these disorders. Oral contraceptives increase the risk of blood clots (which can also contribute to heart attacks and strokes). So, women with a high triglyceride level should not take combination oral contraceptives.

Rarely, a noncancerous liver tumor (hepatocellular adenoma Hepatocellular Adenoma A hepatocellular adenoma is a relatively uncommon noncancerous liver tumor that may be mistaken for cancer. Rarely, it ruptures and bleeds or becomes cancerous. (See also Overview of Liver Tumors... read more ) develops. If this tumor suddenly ruptures and bleeds into the abdominal cavity, emergency surgery is required. However, such bleeding is rare. Taking oral contraceptives for a long time and in high doses increases the risk of developing this tumor. The tumor usually disappears after oral contraceptives are stopped.

Taking certain drugs can make oral contraceptives less effective. These drugs include the following:

If women taking oral contraceptives have to take one of these drugs, they should also use another contraceptive method while they are taking the drug, and they should continue using another contraceptive method until their first period occurs after they stop the drug. Women should not take lamotrigine (an antiseizure drug) with oral contraceptives. Oral contraceptives may make lamotrigine less effective in controlling seizures.

A woman must not take combination oral contraceptives (tablets that contain estrogen and a progestin) if any of the following conditions are present:

Oral contraceptives cause no increase, or possibly a small increase, in the risk of breast cancer in women who are currently taking them or who took them within the past few years.

For healthy women who do not smoke, taking low-dose combination tablets with a low dose of estrogen does not increase the risk of having a stroke or heart attack.

A contraceptive skin patch is attached to the skin with an adhesive. It should be left in place for 1 week, then removed and replaced with a new patch, which is placed on a different area of the skin. A new patch is applied once a week (on the same day each week) for 3 weeks, followed by a week when no patch is used.

If more than 2 days go without using the patch, women should use a backup contraceptive method for 7 days in addition to the patch. If 2 days go by and women have had unprotected intercourse in the 5 days before those 2 days, they can consider emergency contraception Emergency Contraception Emergency contraception is used after an act of unprotected sexual intercourse or after an occasion when a contraceptive method fails (for example, when a condom breaks). Emergency contraception... read more .

Exercise and use of saunas or hot tubs do not displace the patch.

The patch may be less effective in women who weigh more than 198 pounds or have a body mass index Obesity (BMI) of 30 or more.

Spotting or bleeding between periods (breakthrough bleeding) is uncommon. Irregular bleeding becomes more common the longer women use the patch.

Skin under and around the patch may become irritated.

A vaginal ring is a small flexible, soft, transparent device that is placed in the vagina.

Two types of rings are available:

Both types are left in place for 3 weeks, then not used for 1 week to allow the menstrual period to occur.

A woman can place and remove the vaginal ring herself. The ring comes in one size and can be placed anywhere in the vagina.

Women may wish to remove the vaginal ring at times other than after 3 weeks. However, if the ring is removed for more than 3 hours, women should use a backup contraceptive method for 7 days in addition to the ring.

Usually, the vaginal ring is not felt by the woman’s partner during intercourse. The ring does not dissolve and cannot be pushed too far up.

If women use a patch or a ring for 3 weeks (replacing it each week), followed by 1 week when no patch or ring is used, they typically have a regular menstrual period. Spotting or bleeding between periods (breakthrough bleeding) is uncommon. Irregular bleeding becomes more common the longer women use the ring.

Side effects Disadvantages Contraceptive hormones can be Taken by mouth (oral contraceptives) Inserted into the vagina (vaginal rings) Applied to the skin (patch) Implanted under the skin read more , effects on the risk of developing disorders, and restrictions on use are similar to those of combination oral contraceptives.

The progestin completely disrupts the menstrual cycle. About one third of women using this contraceptive have no menstrual bleeding during the 3 months after the first injection, and another third have irregular bleeding and spotting for more than 11 days each month. After this contraceptive is used for a while, irregular bleeding occurs less often. After 2 years, about 70% of the women have no bleeding at all. When the injections are stopped, a regular menstrual cycle resumes in about half the women within 6 months and in about three fourths within 1 year. Fertility may not return for up to 18 months after injections are stopped.

Women typically gain 3 to 9 pounds during the first year of use and continue to gain weight. The weight gain is probably due to changes in appetite. So to prevent this gain, women need to limit calories and increase the amount of exercise they do.

Medroxyprogesterone acetate does not appear to worsen depression in women who have depression before they start this drug.

Headaches are common, but they usually become less severe over time. If women have had tension headaches or migraines in the past, the injections do not make them worse.

Bone density temporarily decreases. However, the risk of fractures does not increase, and bones usually return to their previous density after the injections are stopped. Getting enough calcium and vitamin D daily to help maintain bone density is important for all women, but it is particularly important for adolescent and young women who are getting progestin injections. Calcium and vitamin D supplements are often needed to get the required amount.

Medroxyprogesterone acetate does not increase the risk of developing breast, ovarian, or cervical cancer.

It reduces the risk of developing

Interactions with other drugs are uncommon.

Unlike combination oral contraceptives, progestin injections do not appear to increase the risk of high blood pressure or blood clots. However, in some women, medroxyprogesterone acetate increase the levels of triglycerides and low-density lipoprotein (LDL) cholesterol. High levels of these fats (lipids) may increase the risk of atherosclerosis Plaque rupture Atherosclerosis is a condition in which patchy deposits of fatty material (atheromas or atherosclerotic plaques) develop in the walls of medium-sized and large arteries, leading to reduced or... read more and blood clots.

Medroxyprogesterone acetate is currently considered safe for women who should not take estrogen and may be a good choice for women with a seizure disorder.