About Combined Birth Control Pills
Summary
The birth control pill, often called “the pill,” is a daily oral contraceptive that contains a combination of estrogen and a progestin. These hormones work together to prevent pregnancy by suppressing ovulation, thickening cervical mucus, and thinning the uterine lining. The pill is one of the most commonly used forms of reversible birth control and can also provide non-contraceptive benefits such as regulating menstrual cycles, reducing menstrual cramps and heavy bleeding, improving acne, and helping manage symptoms of conditions such as polycystic ovary syndrome (PCOS). When taken consistently and correctly, the pill is highly effective at preventing pregnancy. Because it requires daily use, it may be best suited for patients who are comfortable maintaining a regular medication routine.
Why a Patient Might Choose This Method
A patient may choose the birth control pill because it is a highly effective, non-invasive contraceptive option that can be started and stopped easily without a medical procedure. In addition to preventing pregnancy, birth control pills can help regulate menstrual cycles, reduce menstrual cramps, decrease heavy bleeding, and improve acne in some patients. The pill is available in both combined estrogen-progestin and progestin-only formulations, allowing providers to tailor treatment to a patient’s individual needs and medical history.
A major advantage of the combined hormonal pill (unlike the progestin-only mini-pill) is that it can be used to skip or reduce menstrual periods by taking the active hormone pills continuously and skipping the placebo pills. Many patients find this advantageous because it can reduce the inconvenience of monthly bleeding, menstrual cramps, headaches, bloating, and other symptoms associated with the menstrual cycle. Continuous use may also be beneficial for patients with conditions such as endometriosis, heavy menstrual bleeding, menstrual migraines, or severe premenstrual symptoms. For many individuals, having fewer or no periods can improve quality of life, increase convenience, and reduce the impact of menstrual symptoms on daily activities.
How It Is Used
Birth control pills are taken by mouth at the same time each day. Most pill packs contain either 21 active pills followed by 7 placebo pills, or 24 active pills followed by 4 placebo pills, although other schedules are available. During the placebo days, many patients experience withdrawal bleeding that resembles a menstrual period. Some patients use pills continuously to reduce or eliminate bleeding. Taking the pill consistently every day is important for maintaining its effectiveness and preventing pregnancy.
Starting the Pill
Combined oral contraceptive pills can be started in several different ways depending on when treatment begins and individual circumstances. Your healthcare provider can help determine which option is most appropriate and whether backup contraception is needed during the first week.
| Method | When to Start | When Protection Begins |
|---|---|---|
| First-Day Start | Take the first pill on the first day of menstrual bleeding. | Immediate protection; no backup contraception needed. |
| Sunday Start | Take the first pill on the first Sunday after the period begins (or on the same Sunday if the period starts on Sunday). | Use backup contraception for the first 7 days. |
| Quick Start | Take the first pill on the day the prescription is received, regardless of where the patient is in the menstrual cycle (after reasonably excluding pregnancy). | Use backup contraception for the first 7 days. |
| Day 1–5 Start | Start within the first 5 days of the menstrual period. | Generally protected immediately if started within the first 5 days of bleeding. |
| Postpartum Start | Timing depends on breastfeeding status and risk factors for blood clots. | Follow provider guidance; backup contraception may be needed initially. |
Quick Start
Quick Start is often preferred because it allows patients to begin contraception immediately rather than waiting for their next period. If pregnancy can reasonably be ruled out, the pill can be started the same day it is prescribed. A backup contraceptive method, such as condoms, should be used for the first 7 days.
You do not have to wait for your next period to start the birth control pill. Many patients begin the pill immediately using the Quick Start method. Depending on when you start in your cycle, you may need to use a backup method such as condoms for the first 7 days. Starting on the first day of your period provides immediate protection, while other start methods generally require a short backup period.
Options and Comparisons
Phasic Birth Control Pills: Understanding Monophasic, Biphasic, and Triphasic Pills
Some combined hormonal birth control pills contain the same hormone dose every day, while others vary the hormone dose throughout the month to more closely mimic the body’s natural menstrual cycle. These are referred to as monophasic, biphasic, and triphasic pills.
Monophasic Pills
Summary
Monophasic pills contain the same dose of estrogen and progestin in every active pill throughout the cycle. Because hormone levels remain consistent, monophasic pills are the most commonly prescribed type of combined oral contraceptive.
Why a Patient Might Choose This Type
A patient may choose a monophasic pill because it provides the same hormone dose every day, making it simple to use and often easier to manage. Monophasic pills are commonly used for continuous or extended-cycle dosing to skip periods and may be preferred for patients who experience mood changes, headaches, or breakthrough bleeding related to hormone fluctuations.
How It Is Used
Monophasic pills are taken once daily. Each active pill contains the same amount of estrogen and progestin, followed by placebo pills or a hormone-free interval, depending on the product. Some patients may take monophasic pills continuously to reduce or eliminate menstrual bleeding.
Biphasic Pills
Summary
Biphasic pills contain two different hormone dose levels during the active pill portion of the cycle. The hormone dose changes once during the month in an attempt to more closely resemble natural hormonal fluctuations.
Why a Patient Might Choose This Type
A patient may choose a biphasic pill if they and their healthcare provider feel that a changing hormone dose may improve cycle control or reduce certain side effects. While less commonly prescribed today, biphasic pills remain an option for some patients who do not achieve satisfactory results with monophasic formulations.
How It Is Used
Biphasic pills are taken once daily in the order provided in the package. The hormone dose changes during the cycle, so pills should be taken in sequence and not mixed between weeks.
Triphasic Pills
Summary
Triphasic pills contain three different hormone dose levels during the active pill cycle. The hormone amounts change approximately every week to mimic the body’s natural hormone patterns more closely.
Why a Patient Might Choose This Type
A patient may choose a triphasic pill if they experience breakthrough bleeding or side effects with other pill formulations. Some patients tolerate the changing hormone doses well and achieve excellent cycle control.
How It Is Used
Triphasic pills are taken once daily in the order provided in the package. Because the hormone doses change throughout the cycle, it is important to follow the pill sequence exactly as directed.
Types of Phasic Birth Control Pills
Combined birth control pills are available in several hormone dosing patterns. The best option depends on your health history, treatment goals, bleeding pattern, and personal preferences. Your healthcare provider can help determine which formulation is most appropriate for you.
| Type | Hormone Pattern | Advantages | Potential Disadvantages | Common Brands |
|---|---|---|---|---|
| Monophasic | Same hormone dose in every active pill | Simple regimen, easier continuous use, fewer hormone fluctuations | May not be ideal for every patient | Sprintec, Yasmin, Yaz, Junel, Loestrin |
| Biphasic | Two hormone dose levels during cycle | May improve cycle control for some patients | More complex regimen, fewer available options | Mircette (sometimes categorized as biphasic/modified phasic) |
| Triphasic | Three hormone dose levels during cycle | Mimics natural hormonal changes more closely | More complex regimen, less flexible for continuous use | Ortho Tri-Cyclen, Tri-Sprintec, Tri-Lo-Marzia |
Quick Decision Guide
Use this guide as a general reference when comparing different types of birth control pills. Your provider will recommend the option that best matches your medical history and treatment goals.
| If You Want… | Consider |
|---|---|
| The simplest pill schedule | Monophasic |
| To skip periods or use continuous dosing | Monophasic |
| The most commonly prescribed pill type | Monophasic |
| A formulation that changes hormone levels during the cycle | Biphasic or Triphasic |
| A pill that more closely mimics natural hormone fluctuations | Triphasic |
| Maximum flexibility for cycle manipulation | Monophasic |
Clinical Pearl
Research has not consistently shown that biphasic or triphasic pills are more effective or safer than monophasic pills. For most patients, the choice comes down to individual tolerance, bleeding patterns, and personal preference. Because monophasic pills contain the same hormone dose every day, they are often the easiest option for patients who wish to skip periods or use extended-cycle contraception.
Hormone Reference
Hormones by Birth Control Type
Different birth control methods contain different hormones. Some contain both an estrogen and a progestin, while others contain only a progestin. Understanding which hormones are used can help explain how each method works and why certain options may be recommended for different patients.
| Method | Active Drug(s) |
|---|---|
| Combined Pill | Ethinyl estradiol + progestin |
| Progestin-only Pill | Norethindrone, Drospirenone, Desogestrel (varies by country) |
| Patch | Ethinyl estradiol + Norelgestromin or Levonorgestrel |
| Vaginal Ring | Ethinyl estradiol + Etonogestrel or Segesterone Acetate |
| Implant | Etonogestrel |
| Hormonal IUD | Levonorgestrel |
| Injection | Medroxyprogesterone Acetate |
| Emergency Contraception | Levonorgestrel or Ulipristal Acetate |
Understanding Progestins
Different progestins have unique properties that may influence acne, bleeding patterns, mood, water retention, androgenic effects, and long-term contraception. The most appropriate choice depends on each patient’s health history and treatment goals.
| Goal | Progestins Often Favored |
|---|---|
| Acne improvement | Drospirenone, Norgestimate, Dienogest, Cyproterone Acetate |
| Lowest androgenic effects | Drospirenone, Dienogest, Nomegestrol, Desogestrel |
| Long-acting contraception | Levonorgestrel (IUDs), Etonogestrel (implant), Medroxyprogesterone (injection) |
| Most extensive safety history | Levonorgestrel, Norethindrone |
| Heavy menstrual bleeding | Levonorgestrel IUDs (especially Mirena, Liletta) |
| PMDD symptoms | Drospirenone-containing pills (e.g., Yaz) |
Comparing Progestins
Each progestin has its own characteristics, advantages, and potential drawbacks. Some are preferred for acne or heavy periods, while others have the longest safety history or are used primarily in long-acting contraceptives.
| Progestin | Primary Characteristics / Function | Potential Advantages | Potential Disadvantages | Common Brand Products |
|---|---|---|---|---|
| Levonorgestrel | Potent progestin; suppresses ovulation, thickens cervical mucus | Extensive safety data, effective, lower clot risk than some newer progestins | More androgenic; may worsen acne or oily skin | Mirena, Kyleena, Skyla, Liletta, Plan B, Aviane, Seasonale |
| Norgestrel | Similar to levonorgestrel | Reliable contraception, inexpensive | More androgenic side effects | Low-Ogestrel, Cryselle |
| Norgestimate | Lower androgenic activity | Often preferred for acne-prone patients | May cause breakthrough bleeding initially | Ortho Tri-Cyclen, Sprintec, Tri-Sprintec |
| Desogestrel | Third-generation progestin with low androgenicity | Less acne/hirsutism | Slightly higher VTE (blood clot) risk when combined with estrogen | Desogen, Mircette, Apri |
| Etonogestrel | Active metabolite of desogestrel | Long-acting, highly effective | Irregular bleeding common | Nexplanon, NuvaRing |
| Drospirenone | Anti-androgenic and anti-mineralocorticoid | May improve acne, PMS/PMDD symptoms, water retention | Slightly higher clot risk with estrogen; can increase potassium | Yaz, Yasmin, Nextstellis, Slynd |
| Norethindrone | First-generation progestin | Well-established safety profile; common mini-pill | More androgenic effects possible | Micronor, Camila, Errin |
| Norethindrone Acetate | Modified norethindrone | Good cycle control | May contribute to androgenic side effects | Loestrin, Junel, Microgestin |
| Dienogest | Strong anti-androgenic activity | Useful for acne and endometriosis symptoms | Less widely available in the U.S. | Natazia |
| Nomegestrol Acetate | Highly selective progesterone receptor activity | Favorable bleeding patterns | Limited availability in some countries | Zoely |
| Medroxyprogesterone Acetate | Long-acting injectable progestin | Only needed every 3 months; highly effective | Weight gain, delayed return to fertility, possible bone density loss | Depo-Provera |
| Norelgestromin | Active metabolite of norgestimate | Convenient weekly patch | Estrogen-containing patch may increase clot risk | Xulane, Zafemy |
| Segesterone Acetate | Newer progestin for vaginal ring use | One ring used for a year | Limited long-term experience compared with older agents | Annovera |
| Ethynodiol Diacetate | Older progestin | Good cycle control in some patients | More breakthrough bleeding in some users | Zovia |
| Lynestrenol | Older progestin used mainly outside the U.S. | Effective progestin-only option | Less commonly available | Exluton |
| Chlormadinone Acetate | Anti-androgenic progestin | May improve acne and hirsutism | Not approved in the U.S. for contraception | Belara |
| Cyproterone Acetate | Strong anti-androgenic effects | Often used for severe acne or excess hair growth | Higher clot risk when combined with estrogen | Diane-35 (outside U.S.) |
| Megestrol Acetate | Potent progestin; rarely used for contraception | Primarily used for appetite stimulation and oncology | Weight gain, not commonly used in contraceptives | Megace |
| Quingestanol Acetate | Older progestin | Historical contraceptive use | Rarely used today | Limited current availability |
Understanding Estrogens
Although several estrogens are used in hormonal contraception, they differ in potency, metabolism, and clinical characteristics. Ethinyl estradiol remains the most widely used estrogen in combined hormonal contraceptives.
| Estrogen | Primary Characteristics / Function | Potential Advantages | Potential Disadvantages | Common Brand Products |
|---|---|---|---|---|
| Ethinyl Estradiol (EE) | Synthetic estrogen; most common estrogen in contraceptives; suppresses FSH and stabilizes the uterine lining | Extensive safety data, excellent cycle control, widely available | Dose-dependent risk of blood clots, nausea, breast tenderness, headaches | Yaz, Yasmin, Sprintec, Ortho Tri-Cyclen, Loestrin, Junel, Aviane, Seasonique, Xulane, NuvaRing |
| Estradiol | Bioidentical estrogen identical to natural ovarian estrogen | More physiologic hormone profile; may have fewer estrogen-related side effects for some users | Less potent than EE, requiring specialized formulations | Some newer combined oral contraceptives |
| Estradiol Valerate | Prodrug converted to estradiol in the body | More closely mimics natural estrogen production; effective cycle control | Fewer available products and less long-term contraceptive experience than EE | Natazia |
| Estetrol (E4) | Newer estrogen based on a naturally occurring human estrogen; manufactured synthetically | May have less impact on liver proteins and clotting factors; favorable bleeding profile | Newer medication with less long-term clinical experience | Nextstellis |
| Mestranol | Older synthetic estrogen converted to ethinyl estradiol in the body | Historically effective contraceptive estrogen | Largely replaced by ethinyl estradiol; less commonly prescribed today | Older oral contraceptive formulations |
Comparing Estrogens
This comparison summarizes the relative potency of the estrogens used in hormonal contraceptives.
| Estrogen | Relative Potency | Natural vs. Synthetic |
|---|---|---|
| Ethinyl Estradiol | Highest | Synthetic |
| Mestranol | High (converted to EE) | Synthetic |
| Estradiol | Moderate | Natural / Bioidentical |
| Estradiol Valerate | Moderate (converted to estradiol) | Natural / Bioidentical derivative |
Clinical Pearl
Many medications and supplements can affect how birth control pills work. Patients should inform their healthcare provider about all prescription medications, over-the-counter products, and herbal supplements they take, particularly certain anti-seizure medications, rifampin, and St. John’s wort.
Extended-Cycle Birth Control Pills
Summary
Extended-cycle birth control pills are combined hormonal contraceptives designed to reduce the number of menstrual periods a patient experiences each year. Instead of having a monthly withdrawal bleed, patients may have periods every three months or may choose to eliminate scheduled bleeding altogether. These pills contain the same types of estrogen and progestin found in traditional birth control pills but are packaged and taken differently to provide longer intervals between bleeding episodes. Extended-cycle pills are often chosen by patients who want fewer periods, experience significant menstrual symptoms, or prefer the convenience of less frequent bleeding.
Why a Patient Might Choose This Method
A patient may choose an extended-cycle pill if they would like to have fewer menstrual periods throughout the year. Many patients find this beneficial because it can reduce menstrual cramps, headaches, bloating, heavy bleeding, menstrual migraines, endometriosis symptoms, and the inconvenience associated with monthly periods. Extended-cycle pills provide the same contraceptive benefits as traditional birth control pills while allowing greater control over the timing and frequency of bleeding.
How It Is Used
Extended-cycle pills are taken every day, similar to traditional birth control pills. However, instead of taking active hormone pills for 3 weeks followed by a hormone-free week each month, active pills are taken continuously for a longer period of time. Some products provide a scheduled period every 3 months, while others may be taken continuously to minimize or eliminate bleeding altogether. Breakthrough spotting may occur during the first few months of use but often improves over time.
Types of Extended-Cycle Pills
Extended-cycle birth control pills reduce the number of scheduled menstrual periods by providing active hormone pills for longer periods before a hormone-free or low-hormone interval. Some products are specifically packaged for extended use, while many standard combined pills can also be taken continuously under the guidance of a healthcare provider.
| Brand Name | Hormones | Schedule | Advantages | Potential Disadvantages |
|---|---|---|---|---|
| Seasonale | Ethinyl Estradiol + Levonorgestrel | 84 active pills + 7 placebo pills | Only 4 periods per year; extensive clinical experience | Breakthrough bleeding common initially |
| Seasonique | Ethinyl Estradiol + Levonorgestrel | 84 active pills + 7 low-dose estrogen pills | Fewer hormone fluctuations during the placebo week | Spotting may occur during the adjustment period |
| Camrese / Camrese Lo | Ethinyl Estradiol + Levonorgestrel | Similar to Seasonique | Reduced frequency of periods | Breakthrough bleeding possible |
| Quartette | Ethinyl Estradiol + Levonorgestrel | Extended-cycle with gradually increasing estrogen doses | Designed to reduce breakthrough bleeding | More complex regimen |
| Amethyst | Ethinyl Estradiol + Levonorgestrel | Continuous active pills year-round | May eliminate periods entirely | Irregular spotting common initially |
| Continuous Use of Standard Combined Pills | Varies | Active pills taken continuously | Flexible and widely available | Not specifically packaged for extended use |
Quick Decision Guide
This guide provides a general comparison of common extended-cycle options. Your healthcare provider can help determine which regimen best fits your medical history, lifestyle, and treatment goals.
| If You Want… | Consider |
|---|---|
| Only 4 periods per year | Seasonale |
| Fewer periods with lower hormone fluctuations | Seasonique or Camrese |
| A regimen designed to reduce breakthrough bleeding | Quartette |
| To potentially eliminate periods completely | Amethyst |
| Maximum flexibility using a standard birth control pill | Continuous use of a traditional combined pill |
| Relief from menstrual migraines, endometriosis symptoms, or severe menstrual symptoms | Any extended-cycle option, especially continuous regimens |
Clinical Pearl
Extended-cycle pills do not “store up” menstrual blood or cause a buildup inside the body. The bleeding experienced during traditional birth control use is typically withdrawal bleeding rather than a true menstrual
Ready to discuss birth control options?
Choosing a birth control method can feel overwhelming, but you do not have to sort through the options alone. APNS can help you review your health history, preferences, and goals so you can make an informed decision with guidance from a healthcare provider.