The pill, patch and vaginal ring: General information

The birth control pill, birth control patch and vaginal ring are prescription medications made of synthetic hormones. When used as directed, they're highly effective in preventing pregnancy. These methods of birth control are also easily reversible.

Birth control pill
There are two types of birth control pills: combination pills and progestin-only minipills.

The most common type of oral contraceptive is the combination pill, which contains the two hormones estrogen and progestin. Estrogen suppresses ovulation (the ripening and release of a mature egg from one of the ovaries) by preventing stimulation of the ovary (the female gland that produces female sex hormones and eggs for reproduction). To make it more difficult to conceive, progestin suppresses the release of a ripened egg and makes the lining of the uterus and the cervical mucus less hospitable.

The minipill contains only the hormone progestin. The minipill works mainly by thickening cervical mucus and interfering with egg implantation. Because minipills don't suppress ovulation consistently, your doctor may recommend using a backup method of birth control at midcycle, when ovulation typically occurs. It's essential to take the minipill at the same time each day. Just one late or missed dose can undo any contraceptive protection.
Birth control patch
The birth control patch (Ortho Evra) is a new form of combination contraception (containing estrogen and progestin) that's now available by prescription. The patch, which is worn on the skin, contains hormones similar to those in combination pills and prevents pregnancy in the same way. A new patch is applied each week on the same day of the week for three consecutive weeks. A patch is not worn the fourth week, when you'll have your period.

Vaginal ring
The vaginal ring (NuvaRing) is another new method of combination contraception. It's a flexible ring-shaped device that's worn in the vagina for three weeks and then removed for the fourth week, when you'll have your period. The vaginal ring continuously releases two hormones similar to those found in combination birth control pills to inhibit ovulation, thicken the cervical mucus, and make the uterus lining less hospitable to an egg. A new ring is inserted every month.


Effectiveness
The combination pill, minipill, patch and vaginal ring are more than 99 percent effective in preventing pregnancy when taken exactly as prescribed, and 92 percent effective with typical use (which allows for the fact that they may not always be used correctly). The patch may be less effective in women who weigh more than 198 pounds, however.

When hormonal contraception shouldn't be used
Birth control pills, patches and vaginal rings are safe and convenient for most women. In certain situations, however, an alternative method of contraception may be recommended.
Combination pill, patch or vaginal ring
Women over age 35 who smoke should not use combination contraceptives, nor should women who have:

a personal or close family history of blood clots in the legs or lungs
cerebrovascular disease (conditions involving blood vessels in the brain), such as stroke
coronary artery disease or certain other heart conditions
uncontrolled high blood pressure
breast cancer
endometrial cancer
certain liver or gall bladder diseases
diabetes for more than 20 years or with complications involving the blood vessels, nerves, kidneys or eyes
migraine headaches with auras (a sensation that occurs before the migraine starts, such as seeing flashing lights or developing a temporary blind spot)
unexplained vaginal bleeding
major surgery with prolonged immobilization
surgery on the legs
If you have various other conditions or take certain medications, a different type of contraceptive may also be recommended. Be sure to discuss your medical history thoroughly with your doctor before choosing one of these methods of birth control.

If you were exposed before birth to diethylstilbesterol (DES) (a synthetic estrogen that was given to some pregnant women in the United States until the early 1970s), talk to your doctor about the risks and benefits of combination contraceptives, which contain estrogen. Although these medications have not been shown to be unsafe for women who were exposed to DES, some doctors suggest avoiding them.

After the birth of a baby, combination contraceptives should be avoided for at least six weeks if you choose to breastfeed because the hormones will pass into your breast milk. For up to six months, these methods may also diminish your milk production.

Minipill
Women who have breast cancer, certain liver diseases or unexplained vaginal bleeding should not take the progestin-only minipill. Taking certain medications may also restrict use of the minipill.

Unlike the combined pill, patch and vaginal ring, the minipill can be taken soon after the birth of a baby because it doesn't adversely affect breast milk. In some cases, it may even increase milk production.


Schedules
Birth control pills are most effective when taken at the same time every day. The patch should be changed on the same day each week. A new vaginal ring should be inserted every four weeks. For any type of birth control, make sure you understand and carefully follow the specific instructions printed on the label or package insert. Here are some general guidelines.
Birth control pill
Schedules may vary according to brand or type of pill. You may be instructed to take the first pill on the first day of your period or the first Sunday after your period begins. If you're certain you're not pregnant, you may be instructed to take the first pill right away. If you're considering alternate dosing schedules so you don't get your period every month, consult your doctor about the specifics.


Combined pill: With 28-day packs, you take a pill each day for 28 consecutive days and then immediately begin the next pack. For the last seven days, you're taking a pill that usually doesn't contain any medication. These seven pills are a different color than the other 21 pills in the pack. The reasoning behind the "blank" pills is to help you maintain the habit of taking a pill every day. You'll have your period each month during the week you take the blank pills. With 21-day packs, you stop taking the pill for seven days each month and then resume with a new pack. You'll have your period each month during the week you don't take any pills. Discuss your preferences with your doctor.
A new 91-day pack of combined pills (Seasonale) is now available. With this option, you take a pill each day for 91 consecutive days and then begin a new pack. For the last seven days, you're taking blank pills that don't contain any medication. These seven pills are a different color than the other 84 pills in the pack. You'll have your period during the week you take the blank pills -- once every three months.

To help maintain a steady level of hormones in your system, it's best to take the pill about the same time each day. It may help to take the pill when you do another routine daily activity, such as eating breakfast, brushing your teeth or going to bed. Each day, check your pack of pills to make sure you took your pill the day before.


Minipill: There are 28 pills in a pack of minipills. Each pill contains the hormone progestin, so each pill is important in preventing pregnancy. To maintain a steady level of hormones in your system, it's essential to take the minipill at the same time each day. It may help to take the pill when you do another routine daily activity, such as eating breakfast or brushing your teeth. When choosing the time of day you take the pill, remember that it's less effective during the last few hours before the next dose is due. Each day, check your pack of pills to make sure you took your pill the day before. Unlike the combination pill, the minipill will not regulate your periods to the last week of the pack. You'll continue to have your periods on your usual schedule.
Birth control patch
Like birth control pills, you may be instructed to apply your first patch on the first day of your menstrual period or on the first Sunday after your period starts. Whichever day you start will be your "patch change day." Your second and third patch of every month should be changed on the same day of the week as the day you started.

The patch may be placed on your stomach, back, chest (except for the breast area), buttocks, or the upper outer portion of your arm. When replacing your patch each week, apply it in a different area to avoid any possible skin irritation. And remember, your fourth week is a "patch-free" week. During this week, you'll have your period.

Vaginal ring
The vaginal ring should be inserted on or before the fifth day of your period, counting the first day of your period as day one. To insert the vaginal ring, carefully follow the manufacturer's instructions. Because it's inserted into the upper part of the vagina, it should be comfortable and not interfere with sex. Three weeks later, you'll remove the ring. The fourth week is a "ring-free" week. You'll have your period during the ring-free week. After the fourth week, insert a new ring. Because the vaginal ring's effectiveness is based on the release of hormones, insert the new ring at the same time of day it was removed the previous week.

If you plan to use the vaginal ring and have recently been using a hormonal form of contraception (such as birth control pills or injections), discuss with your doctor when it would be best to first insert the ring.


Taking a break
There is no documented benefit to taking an occasional break from hormonal contraceptives. Taking a break won't decrease the side effects you may experience once you begin using hormonal contraceptives again, and being off the contraception may result in an unplanned pregnancy.

Prevention of sexually transmitted diseases
Birth control pills, patches and vaginal rings don't offer protection from HIV or other sexually transmitted diseases (STDs). It's important to practice safe sex with a male or female condom to help prevent these infections. If you're exposed to an STD, contact your doctor for testing and treatment.

Backup birth control
In certain situations, you may need a backup method of birth control, such as condoms and spermicide. If in doubt, ask your doctor how long you should use a backup method of birth control. Here's a general guide.
Starting a new pack or method: If you begin taking birth control pills or apply the patch after the fifth day of your cycle (five days after your period begins), contraception may not be effective immediately. Use a backup method of birth control for at least seven days. For Sunday start pills, a backup method is typically recommended for seven days as well. After inserting your first vaginal ring, use a backup method of birth control for at least seven days.

Minipills at midcycle: Because minipills don't suppress ovulation, consider a backup method of birth control at midcycle, when ovulation occurs.

Taking certain medications: Certain medications can lower the effectiveness of birth control pills, patches and vaginal rings, also making backup birth control a good idea. Whenever another drug is prescribed for you, ask if it may interfere with your method of birth control.

When you're sick: If you take combination pills and have severe diarrhea, vomiting, use an additional method of birth control while you're sick through seven days after the illness. If you take the minipill and have diarrhea or vomiting, use a backup method of birth control while you're sick through two days after the illness. Diarrhea or vomiting shouldn't alter the effectiveness of the patch or the vaginal ring.

Missed pill, patch or vaginal ring: If you're very late taking a pill or applying a patch, miss a pill or patch completely, or leave the vaginal ring in more than a week too long, you may not be protected from pregnancy for seven days or longer. Be sure to use a backup method of birth control during this time. If the vaginal ring falls out or is displaced during sex, rinse it with water and reinsert it within three hours. If you wait more than three hours, use a backup method of contraception until the ring has been in place continuously for seven days.


Emergency contraception
If you have unprotected sex and don't want to become pregnant, call your doctor immediately. Emergency hormonal contraception (commonly referred to as the "morning after pill") may help prevent pregnancy. It's taken in two doses. It's best to take the first dose as soon as possible after unprotected sex -- there's no need to wait until the next morning. Treatment will most likely be ineffective if you wait more than 72 hours after sex.

Follow-up care
Follow your doctor's advice about routine medical care and monitoring any changes in your health. An annual exam is recommended for most healthy women with no significant medical conditions. The doctor will do a breast and pelvic exam, check your liver and measure your blood pressure. You may also need a Pap smear (taking a sample of cells from the cervix to screen for cervical cancer) and urinalysis (lab analysis of a urine sample). If you have a significant medical history, you may need a physical exam that includes a blood pressure reading every six months while you're using the pill or patch.
If you're immobilized from an injury, major surgery or serious illness for a period of time, ask your doctor if it would be wise to stop using combination birth control pills, the patch or the vaginal ring.


Benefits
Typically, birth control pills, patches and vaginal rings can be used safely until menopause by healthy nonsmoking women. These methods of contraception are highly effective, which may decrease worry about unplanned pregnancy. They're also convenient to use, requiring no special action just before sexual activity.
Combination pill
Combination birth control pills can be used to treat recurrent or excessive uterine bleeding, dysmenorrhea (pain related to menstruation), acne and excessive hair growth. They may help preserve bone density, and in some cases they're used to help control the symptoms of premenstrual syndrome. They also decrease the risk of:

pelvic inflammatory disease (PID, an infection of the uterus, ovaries and fallopian tubes)
uterine and ovarian cancer
ectopic pregnancy (when the fertilized egg implants itself outside the uterus)
benign breast disease
anemia (a decreased number of red blood cells or hemoglobin, the protein in red blood cells that contains iron)
Combined birth control pills may also decrease the risk of osteoporosis and ovarian cysts (harmless fluid-filled sacs).

Minipill
Progestin-only minipills may be a good choice for women who want to take pills but can't take the combined variety. They can be taken while you're nursing with no effect on your breast milk. Progestin-only pills may offer some protection from endometrial cancer and pelvic inflammatory disease as well.

Birth control patch
Long-term studies are not yet available, but the benefits of the birth control patch are expected to be similar to those of the combination pill. In addition, applying a patch once a week is easier for some women to remember than taking a daily dose of the combined pill.

Vaginal ring
Long-term studies are not yet available, but the benefits of the vaginal ring are expected to be similar to those of the combination pill. The ring is easy to insert and can be easily discontinued.


Risks
Combination pill, patch and vaginal ring
Although many women experience no side effects from the combination pill, patch or vaginal ring, various side effects are possible. For example:


Breakthrough bleeding or spotting may occur between periods. Although certainly a nuisance, true breakthrough bleeding isn't harmful. Breakthrough bleeding is most common during the first three months of birth control pill or patch use. It may occur more often with the 91-day combination pill than with other combination pills. It's less common with the vaginal ring. Factors that may increase the risk of breakthrough bleeding include:

a change in the pill or its dosage
not taking the pill at about the same time every day or not changing the patch on time
missed pills or patches
the use of other medications that may interfere with the contraceptive hormones
smoking
certain infections, such as chlamydia
Start using a backup method of birth control if you suddenly experience breakthrough bleeding or if your period is unusually heavy. It's also important to call your doctor right away. He or she will want to rule out any underlying condition that could be responsible for the abnormal bleeding.


Many women who use combination contraceptives have short, light periods. Others notice just a drop of fresh blood or a brown smudge each month. Some women don't even get their periods, a condition known as amenorrhea.
If you've missed any of your pills or patches or use a vaginal ring more than a week past its change date and you don't have your next period as expected, consult your doctor to determine if you're pregnant. If you've used your pills, patch or vaginal ring as directed, the risk of pregnancy is low. However, it's a good idea to consult your doctor in this case as well. If you're taking low-dose pills, the amount of estrogen may be too low to stimulate enough endometrial growth to cause bleeding when the tissue is sloughed from the uterus each month. There's actually nothing unhealthy about this, and some women consider it a desirable side effect.


Nausea is a common symptom during the first month of taking combination birth control pills. It may be helpful to take the pills with food or just before bedtime. If you have nausea after inserting the vaginal ring, it may help to soak the ring overnight in water before insertion. Call your doctor if the nausea continues for several months. For oral contraceptives, a pill with a lower dose of estrogen may be prescribed.

You may experience headaches or find that your usual headaches worsen. After a few months, these headaches usually improve or subside. Discuss new or changed headaches with your doctor, however. This is especially important if they're accompanied by other symptoms, such as dizziness or changes in your vision.

You may notice breast tenderness or pain during the first few months you use the combination pill, patch or vaginal ring. This tenderness usually improves within a few months.

Very rarely, women who use combination contraceptives become depressed, anxious or experience mood changes. Some women, however, find that their depression actually improves. Complaints of depression are more common in women who take high-dose pills. Consult your doctor if you think you may be experiencing depression, anxiety or mood changes.

Complications associated with combination contraceptives are rare, possibly including:

blood clots
high blood pressure
liver tumors
gallbladder problems
stroke
heart attack
When you're using the combination pill, patch or vaginal ring, it's important to be aware of any warning signs that may indicate a potentially serious medical problem. If you smoke, it's even more important to watch out for warning signs. Remember, other methods of birth control are recommended for women over 35 who smoke.

Seek medical attention immediately if you develop:


severe pain or swelling in the calf or thigh
severe abdominal pain
sudden severe chest pain, coughing or shortness of breath
severe headaches, dizziness, weakness or numbness
eye problems, such as loss of vision or blurring
speech problems, such as slurred speech
a seizure
Minipill
Various side effects of the minipill are possible. For example:


Breakthrough bleeding or spotting may occur between periods. Although certainly a nuisance, true breakthrough bleeding isn't harmful. Breakthrough bleeding is more common with progestin-only pills than with combination pills, and it's usually worse during the first few months. Factors that may increase the risk of bleeding include:

not taking the pill at the same time every day
missed pills
the use of other medications that may interfere with the pill
certain infections, such as chlamydia
Start using a backup method of birth control if you suddenly experience breakthrough bleeding or if your period is unusually heavy. It's also important to call your doctor right away. He or she will want to rule out any underlying condition that could be responsible for the abnormal bleeding.


You may experience headaches or find that your usual headaches worsen. After a few months, these headaches usually improve or subside. Discuss new or changed headaches with your doctor, however. This is especially important if they're accompanied by other symptoms, such as dizziness or changes in your vision.

Very rarely, women who take the minipill become depressed, anxious or experience mood changes. Some women, however, find that their depression actually improves. Consult your doctor if you think you may be experiencing depression, anxiety or mood changes.

Additional side effects may include breast tenderness, nausea, dizziness, acne and unwanted hair growth.

Compared to the combination pill, the minipill has a higher risk of ectopic pregnancy (when a fertilized egg implants itself outside the uterus). Consult your doctor as soon as possible if you miss your period or develop unusual bleeding or abdominal discomfort.

Pregnancy-specific information
Using birth control pills, the patch or the vaginal ring does not increase the risk of future infertility. In fact, in some cases these methods of birth control may help prevent conditions that can interfere with your ability to conceive, such as pelvic inflammatory disease, uterine fibroids, ovarian cysts and endometrial cancer. However, studies have shown that it may take a few months longer for some women who have just discontinued combination birth control pills or patches to become pregnant than women stopping other types of birth control.
Doctors often recommend stopping the pill for three months before trying to get pregnant. This break from the pill helps the doctor more accurately determine when ovulation occurred and, in turn, your due date. If you're using the patch or ring and want to become pregnant, it's recommended that you wait until you have regular periods after stopping the patch or ring before trying to become pregnant. With either method of birth control, consider yourself fertile during this time and use another reliable method of birth control.

Studies have shown that taking birth control pills in the months before pregnancy does not cause birth defects. Most studies show no major malformations, heart defects or limb deformities when birth control pills are taken very early in pregnancy. This applies to pills containing estrogen and progestin, as well as pills containing just progestin. Specific data linking the patch or vaginal ring to infertility and birth defects isn't available, but there doesn't appear to be an increased risk.

There is some concern that taking combination contraceptives within the first two weeks after delivering a baby may increase the risk of thrombosis (a blood clot inside a blood vessel). Ask your doctor for details.