Combined Oral Contraceptives

Birth control pills, also called oral contraceptives or OCs, offer almost complete protection against pregnancy when taken exactly as prescribed. They are available in several types and more than 20 different formulations. Most common are the "combination" pills, which contain synthetic versions of the two major female hormones: estrogen and progesterone. When combination pills originally became available, the dose of hormones was quite high; today much smaller amounts of hormones are used. In addition to the combination pill, there are progestin-only pills or "POPs," which are discussed in Chapter 8.

Combination pills come in three models: single phase, biphasic, and triphasic. All contain an estrogen and progestin (a synthetic form of progesterone), but the biphasic and triphasic pills provide these hormones in amounts that vary from one phase of the monthly cycle to another, in an effort to mimic a woman's natural hormonal cycle.

Birth control pills can be prescribed by physicians, nurse-mid-wives, nurse practitioners, and physician's assistants working in public and private clinics, HMOs, and other health care offices. "The

Pill" today is the most popular form of reversible contraception in the United States.

If you are under age 18 and wonder if the clinic or physician will tell your parents about your visit, you may find it helpful to ask some of the privacy questions listed on page 234 in Chapter 18.

NOTE: Contraceptive pills offer no protection against the AIDS virus and other sexually transmitted diseases.

During sex, a male condom used with a spermicide is the best protection against bacteria and viruses. A number of the women who use the Pill today also use condoms. A long-term, mutually faithful relationship or abstinence also makes it possible to avoid these diseases.

COMBINATION PILLS

As we explain in Chapter 1, the process of ovulation is directed by several hormones. These hormones act in a highly synchronized sequence every month, and the changes in their production by the body cause an egg to mature in one of the ovaries and then be released (ovulated). These changes in hormone production also cause the lining of the uterus to thicken with blood-rich tissue every month, in preparation for nurturing a fertilized egg.

All combination pills contain a synthetic estrogen and a synthetic progestin. They are taken for 3 consecutive weeks; during the fourth week either no pills or blank pills are taken, which causes a period of bleeding like a light menstruation. The Pill prevents pregnancy by means of several different mechanisms. The estrogen in the Pill suppresses certain other hormones that are necessary for ovulation. Without an egg, there can be no pregnancy. The progestin in the Pill causes the cervical mucus to remain thick and sticky, making it very difficult for sperm to get through the cervix to the uterus. It also helps suppress the hormones that govern ovulation.

IN A NUTSHELL

THE PILL

Combined birth control pills are taken by women. Each pill contains hormones, an estrogen and a progestin. These hormones cause changes in your body that prevent you from getting pregnant. The Pill is very effective in preventing pregnancy if it is taken every day about the same time.

The Pill does not protect you against STDs, including AIDS. For protection against disease, you or your partner need to use a condom as well.

You need a prescription from your doctor or a clinic such as Planned Parenthood to buy birth control pills. You can buy them from a drugstore or from the clinic. One pack of pills will last for 1 month. Your doctor or nurse will tell you when to take the first one. The last seven pills are a different color and you will get your period for a few days while taking them. You start the next pack of pills as soon as the first pack is finished.

If you take the Pill you should not smoke, because you increase your risk of a heart attack, stroke, or clots in your blood vessels, even if you are a young woman.

When some women use the Pill, they have mild side effects such as gaining a few pounds, nausea, headaches, bleeding a little between periods, breast tenderness, and acne. If these bother you, tell the nurse or doctor who prescribed the Pill.

It is unusual to have serious side effects, but if you do, call your nurse or doctor right away. These serious effects may be signalled by abdominal pain, very bad headaches, unusual pain in your legs, chest pain, eye problems like blurred vision, or difficulty breathing.

The combination pill is one of the most effective of the reversible methods of birth control available today. There are definite advantages to pills that contain both hormones. The estrogen helps to stabilize the lining of the uterus—the endometrium—so it is less likely to shed between menstrual cycles and cause breakthrough bleeding or spotting. The progestin produces thick cervical mucus that prevents sperm from penetrating, may inhibit ovulation, and alters the lining of the uterus so that it prevents the implantation of a fertilized egg. Both hormones provide some important health benefits, described later in this chapter.

Over the years, changes have been made in the amounts of estrogen and progestin in the Pill. Almost all oral contraceptives now contain greatly reduced levels of both hormones, making them even safer to use.

The Biphasic Pill

The first phased oral contraceptive, Ortho-Novum 10/11, was two-phased (biphasic). With biphasic contraceptives, the pills taken for the first 10 days of the month each contain 0.5 milligram of progestin, and the last 11 pills in the cycle contain 1.0 milligram. The estrogen dose remains steady throughout the cycle at 35 micro-grams.

The Triphasic Pill

The successful introduction of the biphasic pill some years ago led to the development of the triphasic formula. In the triphasic pill, the amounts of both the synthetic estrogen and progestin change during the month. Although phasic pills are promoted as mimicking a woman's natural hormone cycle, not even the manufacturers are sure this makes any difference. The various brands take different approaches to doing this. One product, Ortho-Novum 7/7/7, for instance, uses the same amount of estrogen throughout the month but the amount of progestin changes every 7 days. Two other brands, Triphasil and Tri-Levlen, use a somewhat more potent form of synthetic progestin, and the dose levels change with each phase. The level of estrogen in these two brands also changes from phase to phase. Phases are indicated by different pill colors.

Because each brand of triphasic pills takes a different approach to imitating natural hormone cycles, some experts wonder about the validity of such efforts. If the manufacturers of oral contraceptives were truly trying to copy a woman's natural cycle, these critics point out, all brands of triphasics would follow a single pattern.

Regardless of their individual approaches, the total amounts of estrogen and progestin that phasic pills provide over the course of a month is only a little less than the amount in a month's supply of any low-dose, single-phase, combination pill. All combination pills prevent ovulation and alter the cervical mucus and endometrium, and there is little difference in their effectiveness.

Triphasic pills do have one small drawback. The three phases of different-colored pills sometimes can be difficult to figure out or remember, especially if you are new to oral contraceptives.

HOW EFFECTIVE IS THE PILL?

When taken every day, an oral contraceptive that combines an estrogen and a progestin is extremely effective. In perfect use, a pill that contains at least 30 micrograms of estrogen has about a 1 to 2 percent failure rate. Pills containing 20 micrograms of estrogen have a failure rate of 2 percent.

Among typical users, who may forget a pill occasionally, oral contraception is slightly less effective. Studies of typical users of combination pills reveal a failure rate of up to 3 percent during the first year of use. The effectiveness of an oral contraceptive depends almost entirely on how consistently the pills are taken.

IS THE PILL FOR YOU?

If you have difficulty following instructions or keeping to a schedule, the Pill may be a bad choice for you. If you are coping with a severe depression or a major psychiatric illness, a drug or alcohol dependency, or if you have a history of taking medications incorrectly, other methods may be a better match. Talk to a health care provider—most of them are trained to find the best method for the user.

HOW REVERSIBLE IS THE PILL?

Generally speaking, if you are fertile before you begin using the Pill, your basic ability to conceive will not be affected by this method. Many women become pregnant within a few months after they stopped taking the Pill; for a substantial percentage of women, conception may take 6 months to a year and sometimes longer. This is

AVAILABLE ORAL CONTRACEPTIVES (1996)

Product Manufacturer

CONSTANT-DOSE ORAL CONTRACEPTIVES

Alesse

Wyeth-Ayerst

Brevicon

Roche

Demulen 1/35

Searle

Desogen

Organon

Levlen

Berlex

Lo-Ovral

Wyeth-Ayerst

Modicon

Ortho

Nordette

Wyeth-Ayerst

Norinyl 1+35

Roche

Ortho-Cept

Ortho

Ortho-Cyclen

Ortho

Ortho-Novum 1/35

Ortho

Ovcon 35

Bristol-Myers Squibb

PHASIC ORAL CONTRACEPTIVES

(Except for Desogen, all these products come in 21-day and

28-day packs. A 28-day pack has seven blank pills.)

Ortho-Novum 7/7/7

Ortho

Ortho-Novum 10/11

Ortho

Ortho Tri-Cyclen

Ortho

Tri-Levlen

Berlex

Tri-Norinyl

Roche

Triphasil

Wyeth-Ayerst

ORAL CONTRACEPTIVES WITH 50 |ig OF ESTROGEN (not usual-

ly recommended)

Demulen 1/50

Searle

Norinyl 1+50

Roche

Ortho-Novum 1/50

Ortho

Ovcon 50

Bristol-Myers Squibb

Ovral

Wyeth-Ayerst

(Source: Physicians' Desk Reference,

1996, p. 210)

not very different from the length of time it can take for some women who have not used birth control pills. How long a woman was on the Pill does not appear to affect her return to fertility.

In fact, an inability to conceive does not appear to be related to the Pill itself. Instead, any infertility after pill use is usually due to the woman's age, a physical condition that might have been in existence before she started this method, or problems that may have developed independent of the Pill during its use.

HEALTH EFFECTS

Oral contraceptives have benefits in addition to providing excellent birth control. They protect you against cancer of the ovaries and the endometrium, ovarian cysts, and benign breast lumps. They regularize menstrual cycles and relieve many problems associated with menstruation, such as severe cramps and heavy bleeding.

On the other hand, the Pill may cause some side effects. If you have heart or blood vessel problems, a combined oral contraceptive may not be the best hormonal method for you; instead you may be able to safely use a progestin-only method. Virtually all the research on long-term complications of oral contraceptives was based on the earlier Pills that contained high doses of estrogen and progestin. The few short-term studies of the newer Pills suggest that cardiovascular side effects have declined now that hormone doses are lower.

What has not changed, however, is the dangerous interaction between a combined oral contraceptive and smoking, especially if you are over age 35. If you use the Pill, you should try not to smoke.

The Pill's Benefits

The Pill has protective effects against some common disorders:

• benign breast disease (fibrocystic disease)

• cancer of the ovaries

• cancer of the endometrium

• functional cysts on the ovaries

• iron deficiency anemia caused by heavy menstruation

• pelvic inflammatory disease

• pregnancy in the fallopian tubes (ectopic pregnancy)

• irregular menstrual cycles

Almost all the studies demonstrating these protective effects were conducted with women who had used high-dose oral contraceptives for many years. Although long-term studies of lower-dose pills are not yet available, it seems likely that similar benefits—and fewer side effects—are associated with low-dose pills.

Benign breast disease is less likely. Also known as fibrocystic disease, this is the most common cause of a noncancerous breast lump. The breast feels lumpy and may be tender in the days just before a menstrual period. Women who take birth control pills are less likely to have fibrocystic disease. It is found least often in women who take pills with larger amounts of progestin. This protection increases with every year that the Pill is used and persists for at least a year after it is discontinued.

Protection against ovarian and endometrial cancers. The Pill reduces a woman's risk of cancer of the ovaries or cancer of the endometrium (the lining of the uterus).

Ovarian cancer is the fourth leading cause of cancer deaths in women. It is particularly worrisome because it usually produces no symptoms until it is far advanced. It is fatal for almost 80 percent of the women who develop it. Ovarian cancer is thought to be associated with long stretches of ovulation that are not interrupted by pregnancy and breastfeeding. This cancer is more common today than when women were pregnant frequently and routinely breastfed their children, which meant they did not ovulate for long periods. The Pill may protect against cancer of the ovaries because it stops ovulation. The risk of ovarian cancer in women who ever used the Pill (most of which were higher dose pills) was found to be reduced by 30 to 70 percent. The longer the use, the greater the protection.

Cancer of the endometrium is also a common disease. The risk of endometrial cancer in women who have used the Pill for at least 2 years is about 40 percent less than among women who have never

THE PILL AND SICKLE CELL DISEASE

One of the widely held misconceptions about oral contraceptives is that they cannot be used by a woman who has sickle cell disease, an inherited, chronic, severe anemia. Research has demonstrated that women with sickle cell anemia who take the Pill are not more vulnerable to the sickle crises that occur when the sickle-shaped blood cells block small blood vessels. In fact, the Pill is an excellent contraceptive for these women, for whom pregnancy is dangerous. And even better than the combination pill is the progestin-only pill.

used combined oral contraceptives. The longer a woman uses the Pill, the greater her protection against this cancer.

Fewer functional ovarian cysts. During the menstrual cycle, some ovarian follicles respond to hormone stimulation by continuing to grow instead of bursting open and releasing an egg or simply disappearing at the end of the cycle. These become functional cysts. "Functional" means the cyst is not due to disease but results from the function of the normal cycle. Many times there are no symptoms, but some cysts cause a variety of problems, including abdominal pain, pain during sex, and menstrual difficulties, including delayed menstruation. In three epidemiological studies, the risk of functional ovarian cysts was reduced by the use of birth control pills, probably because the Pill suppresses the normal hormone cycle that stimulates ovulation. In a British study, use of the Pill led to a 64 percent drop in the incidence of these cysts.

Fewer cases of iron deficiency anemia. Iron is essential to the production of hemoglobin, that part of the red blood cell that transports oxygen from the lungs to the rest of the body, where oxygen fuels vital chemical reactions. If a women does not get enough iron in her diet or loses it because of heavy menstruation, she may develop iron deficiency anemia. If this becomes substantial, it can cause a feeling of being tired all the time. Severe forms lead to dizziness, breathing difficulties during physical effort, and angina.

Combined oral contraceptives inhibit the normal development cycle of the lining of the uterus, during which the uterine lining grows rich with extra blood in preparation for the implanting of a fertilized egg. When this does not occur, the amount of monthly bleeding is considerably diminished. Pill users seldom have the heavy periods that are a common cause of iron deficiency anemia in women.

Less chance of pelvic inflammatory disease. About one million women in the United States experience episodes of pelvic inflammatory disease (PID) every year. PID refers to infection in the upper part of the reproductive tract and often follows a sexually transmitted disease. Certain common STDs, such as chlamydia and gonorrhea (the most frequent causes of PID), produce few or no symptoms in the lower genital tract. If not treated, however, they can spread upward through the rest of the reproductive system, causing PID, damaging the fallopian tubes, and leaving scar tissue behind. Every bout of PID does additional damage, greatly increasing a woman's chance of being infertile or having an ectopic pregnancy, a pregnancy that grows in her tubes instead of her uterus.

A major U.S. study of PID in users of oral contraceptives indicated that women who had ever used the Pill had one-half the risk of PID, compared to women their age who did not use oral contraceptives. If a woman were on the Pill for at least 1 year, her risk was reduced by 70 percent. Although the actual mechanism for this protection is not known, researchers believe the thickening of the cervical mucus that occurs during Pill use probably prevents infectious organisms from entering the upper reproductive system. Because the Pill can also shorten menstrual periods and reduce blood flow, the disease organisms that find it easier to enter the sytem during bleeding have less opportunity to do so.

NOTE: Although the Pill appears to protect the upper reproductive system, it offers the lower part of the system—the vagina and cervix—no protection from the microbes that cause herpes, gonorrhea, genital warts, chlamydia, or syphilis. Nor does it protect against hepatitis B or AIDS.

Reduced risk of an ectopic pregnancy. When a pregnancy develops outside the uterus, usually in a fallopian tube, it is called an ectopic, or out-of-place, pregnancy. Currently, about 1 in every 100 pregnancies in the United States is ectopic. These pregnancies are more common in women whose tubes are abnormal or blocked by scar tissue. Sperm may get past the blockage and fertilize an egg, but the egg may implant in the fallopian tube if it is hindered from moving normally toward the uterus. Because the Pill stops ovulation, the chance of an ectopic pregnancy is greatly reduced.

Menstrual cycle benefits. The Pill provides a number of menstrual cycle improvements. It lessens cramps, can shorten the number of days of bleeding, and reduces the amount of blood lost. It improves cycle regularity and decreases the pain some women feel at ovulation. Some women's premenstrual symptoms, including depression and tension, are diminished as well. These effects are especially helpful for women who suffer from premenstrual syndrome and for teenagers who experience difficult and painful periods that interfere with school and other activities.

Other benefits. In addition to the health benefits that the Pill may provide in its role as a contraceptive, it can also be used solely as therapy for several disorders, including dysfunctional uterine bleeding (bleeding that is not normal or cyclical), painful periods, acne, excessive body hair, and endometriosis.

In endometriosis, fragments of the tissue that normally lines the uterus migrate and grow in other places. The fallopian tubes, ovaries, intestines, surface of the bladder, and pelvic wall may be affected. The tissue continues to respond to the menstrual cycle and bleeds each month. Not surprisingly, endometriosis causes considerable pain, especially during menstruation, and can interfere with the normal functioning of the ovaries and fallopian tubes. By reducing the monthly thickening and shedding of the endometrium, oral contraceptives can be an effective treatment for this condition.

FOR THE WOMAN OVER AGE 35

Most experts in family planning feel that healthy, nonsmoking women can use low-dose oral contraceptives until menopause. "Healthy" generally means a woman with no high blood pressure, cardiovascular disease, high blood cholesterol, diabetes, or obesity. Many physicians argue that not only are birth control pills safe for women over age 35, but certain of the Pill's health benefits may have more value as a woman gets older.

A number of obstetricians and gynecologists now believe women should stay on the Pill well into their forties, because the Pill's estrogen will make up for the drop in natural estrogen production that takes place at this time. Maintaining good estrogen levels protects a mature woman against bone thinning and heart disease.

The Pill's Possible Risks

Estrogens and progestins affect many systems in the body, not just the reproductive tract. Anyone taking an oral contraceptive should be aware of possible complications and the symptoms of those complications. When taking the Pill, you should discuss with your health care provider any physical or emotional changes you notice that may be the result of Pill use.

Slightly greater risk of cardiovascular diseases, including thrombophlebitis and blood clots. The most serious complications linked to the Pill since the earliest studies are those of the heart and blood vessels. The risk is increased if you smoke. Severe heart and blood vessel problems, however, are rare in women who take the new low-dose pills and do not smoke.

The formation of blood clots in the veins, particularly in the legs, is perhaps the most common cardiovascular effect, although it does not occur very often. The danger of such clots is that they can break off, get stuck somewhere in the blood system, and block the blood supply to an important organ like the heart, brain, lungs, or eyes. A blood clot usually has no symptoms until it hinders blood flow at some point in the body. It then will affect the function of that organ or tissue and also cause severe pain.

Thrombophlebitis is the inflammation of part of a vein. Its symptoms are swelling, redness, and sensitivity to touch along the course of the involved vein. It also occurs only rarely.

There has been a marked, overall decline in the percentage of women having heart attacks or blood clots associated with taking the Pill. And women who are taking the current low-dose pills are at no greater risk of stroke than women who do not use the Pill, according to a study published in 1996.

NOTE: A woman who wants to use even the low-dose pills should stop smoking, regardless of her age. The risk of heart attack is increased nearly twelvefold in women who smoke. When women smoke and take the Pill, the risk of heart attack increases fiftyfold.

In late 1995, a European study suggested that women who used a combination pill that contained the very new progestins, desogestrel and gestodene, had a greater risk of blood clots than did the users of pills containing older progestins. The reported risk was 30 instances of blood clots in 100,000 women who used these pills. (Just by being pregnant, women have a blood clot risk of 60 per 100,000.) More recent studies have disputed this report.

A WORD OF CAUTION

When a report appears in the media about a newly discovered danger associated with the Pill—or any other method—it is often exaggerated. It is important not to panic but to continue using your contraceptive until you and your doctor have had a chance to learn more about the particular study and whether it applies to you. Unless you want to get pregnant, it is important not to stop using a contraceptive even for a short time. Keeping another birth control method on hand as a backup, and learning to use it, is wise.

Two U.S. brands contain desogestrel: Desogen, made by Orga-non, and Ortho-Cept, made by Ortho. Pills with gestodene are not sold in the United States. If you are using Desogen or Ortho-Cept, you may want to discuss this study with your health care provider.

Diabetes. If you have diabetes but you are healthy otherwise, you may be able to use the Pill, although some experimentation may be necessary to find a Pill formula that does not aggravate the diabetes.

Blood pressure may rise in some women. Both estrogens and progestins may affect blood pressure, and hypertension was associated with earlier Pills. Today, however, it is uncommon in women who take low-dose oral contraceptives. Blood pressure levels may rise slightly in some women but, when the pills are stopped, will drop to former levels in a few weeks. It is wise to have your blood pressure checked periodically after you start any type of drug. If you have a strong family history of early hypertension or have experienced a rise in blood pressure during pregnancy, you should inform your health care provider. In this circumstance, you should be diligent in having your blood pressure checked regularly. If it rises, your provider may suggest a pill with a different formula, or a "minipill" that contains only progestin, or another birth control method entirely.

Possible slight increase in breast cancer risk. A recent, worldwide study of 53,297 women with breast cancer and 100,239 women without this disease concluded that there is a small increase in the risk of breast cancer while women are taking the combined pill or if they have used this method in the past 10 years. There is no evidence of an increase in the risk of having breast cancer diagnosed 10 or more years after stopping the Pill. Women who take a combined oral contraceptive and also have a strong family history of breast cancer, small breast lumps, or abnormal mammograms should always be followed carefully by their physicians.

Possible slight increase in risk of cervical dysplasia. Studies show that women who use oral contraceptives may be at a slightly increased risk of developing cervical dysplasia (abnormal cell changes in the cervix) and cervical cancer. The Pill does not worsen existing dysplasia, however. Even without taking the Pill, any woman who has multiple sexual partners is at increased risk for cervical cancer. The disease is more likely to develop in women who smoke.

It should be noted that mild dysplasia may clear up on its own; more severe dysplasia, which often precedes cervical cancer, can be treated and cured if detected early and treated promptly. An annual Pap test finds almost all cases of dysplasia, usually long before the cell changes develop into cancer. It is important for women who take the Pill, who have many sex partners, and who smoke to have regular Pap tests.

Slight increase in chlamydial cervicitis. Birth control pills can cause a condition in which the cells that usually line the inside of the cervical canal migrate out and around the mouth of the cervix. These migrating cells are more vulnerable to chlamydial infections. The increase in infections, however, is not accompanied by an increase in pelvic inflammatory disease (PID), which often is associated with chlamydia. It is possible that the progestin in the Pill thickens the cervical mucus so the chlamydial organisms are less able to get up into the reproductive tract and damage the fallopian tubes.

Gallbladder disease may develop in certain women. The Pill may accelerate the development of gallbladder disease in women who are already susceptible. Symptoms of gallbladder problems, including gallstones, range from fever and abdominal tenderness to severe pain. Indigestion that is made worse by eating fatty foods also is linked to gallstones.

Common Complaints or Side Effects

The advent of oral contraceptives with a lower dose of hormones has reduced the number of side effects. In general, minor side effects subside after a few months. If you think you are experiencing a side effect and it persists longer than three months, talk to your practitioner about switching to a different pill. Continue taking the pills you have, however, until the prescription is changed or you start another contraceptive method.

Nausea. Although nausea is not a common problem with low-dose pills, it does still occur, usually during the first month or the first few days of each new pack of pills. It seldom causes vomiting. Many women find they can reduce nausea by taking the Pill at bedtime, with a meal, or with an evening snack. If nausea occurs for the first time after months or years of being on the Pill, and cannot be attributed to flu or some other infection, it may be a sign of pregnancy.

Headaches. While taking the Pill, some women develop severe, long-lasting, or recurrent headaches. Women who are prone to migraines may notice an increase in their severity. There is no solid evidence, however, that the Pill increases the frequency of migraines. If your headaches are severe, persistent, and accompanied by vision disturbances, discuss them with your health care provider. You may want to use another form of contraception. If you have occasional migraines that are not too severe, a Pill with less estrogen is less likely to intensify them.

Breast Swelling. Breast swelling is an effect of estrogen that women often experience naturally during their monthly cycle. Low-dose pills seldom cause such swelling so, if it does occur, it is more likely to be a sign of pregnancy.

Fluid Retention. Oral contraceptives occasionally may cause you to retain fluid, resulting in swollen fingers and ankles. Bring this to the attention of your health care provider.

Weight Gain. The progestin in the Pill can cause an increase in appetite and consequent slight weight gain—but it is seldom more than 2 to 4 pounds.

Depression. A large-scale British study in 1985 reported no difference in the incidence of depression among women who were on the Pill and women who used other forms of birth control. Women with a history of depression or mental illness, however, are more likely to experience a worsening of their symptoms while on the Pill.

Interest in Sex. Conflicting reports exist about the effect of the birth control pill on sexual desire. Some Pill users say that their interest in sex diminishes and others find they enjoy sex more because they are no longer afraid of getting pregnant. A few have less vaginal lubrication when they are aroused, which can make sex uncomfortable unless it is remedied by adding a lubricant to the vagina.

Breastfeeding Problems. The combined Pill diminishes milk production and is not recommended when a woman is nursing. In addition, the hormones pass into the milk in small amounts. If you really want to use an oral contraceptive while breastfeeding, you should use a progestin-only pill instead, which will not reduce the supply of breast milk. (See Chapter 17 for more information on breastfeeding and contraceptive use.)

Vision Problems. Double vision, loss of vision, eye pain or swelling, or discomfort while wearing contact lenses are rare side effects of the Pill. If any of these symptoms occurs, you should stop taking the Pill, use another method, and talk with your physician.

Skin Changes. Sometimes a faint, brownish discoloration appears on the cheekbones, forehead, and upper lip when the Pill is being used, and this "mask" will be intensified by sunlight. Known as chloasma or melasma, this masklike effect usually fades in a few months or so if the Pill is discontinued, although in some women it does become permanent.

Menstrual Disturbances

Scanty or Missed Periods. The monthly increase of blood and tissue in the lining of the uterus is almost always reduced when you take birth control pills. As a result, the amount of blood lost every month is less. It is rare, however, for no bleeding to occur during the days the Pill is not taken. If this happens, you should contact your health care provider—it may be a sign of pregnancy.

Breakthrough Bleeding or Spotting. When vaginal bleeding or staining occurs between periods, it is called breakthrough bleeding. This happens more often among women on very low dose pills, on proges-tin-only pills, or on other progestin-only methods. It is more an annoyance than a medical problem. Most breakthrough bleeding occurs during the first months on the Pill. Low estrogen causes the lining of the uterus (endometrium) to become so thin it breaks loose from the uterus at unexpected times. With low-dose pills or proges-tin-only methods, such bleeding can be caused by missing a single pill or by not taking a pill at the same time every day. If the bleeding occurs in more than one cycle and lasts for more than a few days, talk to your practitioner.

Breakthrough bleeding also can appear after you have been on the Pill for a long time. If it occurs early in your cycle, your practitioner may prescribe a small amount of extra estrogen to stop it. If it occurs later, a pill with a stronger form of progestin might be prescribed, to give extra support to the endometrium.

Before your practitioner decides what to do, you should have a physical examination to rule out other possible causes of abnormal bleeding, such as a benign growth or a cancer. If the exam, including a Pap test, reveals no other possible reason for the bleeding, you could switch to a higher dose pill or another method, or you may be able to ignore the bleeding, if it is light and minor.

Early Menstruation. Another form of breakthrough bleeding is menstruation that begins a day or two before you stop taking the monthly schedule of active pills. Continue to take your pills on schedule. If this happens often, check with your health care provider, who may suggest you take a brand with extra estrogen so the endometrium does not shed prematurely.

NOTE: Changing brands may eliminate or reduce annoying side effects. One advantage of using oral contraceptives is that there are many different formulations available. You can try pills with different amounts of estrogen or a different type of progestin to find one that suits you best.

Other Cautions

Because the Pill can be associated with an increased risk of blood clots, it is best to stop birth control pills for three or four weeks before surgery, although this risk has diminished with the low-dose pills.

Because you are more prone to develop blood clots right after childbirth, you shouldn't take the Pill until 14 days after delivery. Unless you are nursing, however, start birth control on or soon after that day—it is possible to ovulate very soon after giving birth. If you are breastfeeding, do not use the combined Pill. If you want an oral contraceptive, use a progestin-only pill. (Chapter 8 describes proges-tin-only pills; Chapter 17 discusses breastfeeding and contraception.)

If you take oral contraceptives after you unknowingly have become pregnant, the risk of your child having any abnormality will not increase above the usual 5 to 6 percent risk that exists for all pregnancies.

If you develop new physical changes such as breast swelling and nausea after using the Pill for some time, you should suspect pregnancy. Talk to your health care provider immediately.

GETTING AND USING THE COMBINATION PILL

A visit to a clinic or a doctor is necessary if you are interested in using the Pill, because oral contraceptives are only sold by prescription. To determine if you are a good candidate for this birth control method, the health care provider will take your personal and family medical history, perform a physical and a pelvic examination, and arrange for any needed lab tests. After the test results are in, if you are considered a good candidate for the Pill, you will be given a prescription for birth control pills. You can fill the prescription at your health center or at any drugstore. One pack of pills lasts 1 month. Many providers prescribe 6 to 12 month supplies of pills to women who have used pills before. (It is not necessary to buy more than one or two packs at a time.)

All but one brand of the Pill are available in either a 21-day or 28-day supply. If you choose the 21-day program, you will stop taking pills for 7 days and then start a new packet. If it is a 28-day pack, the last seven pills are "blanks"—they have no active ingredients. You begin the next pack after finishing the last one. For many women, taking a pill every day lessens the chance of forgetting to start again. If you think there is a chance you might forget to start up again after a week of not taking pills, use the 28-day program. With either pack of pills, you will begin menstruating in the days immediately following the last active pill.

Choose a backup method of birth control. Condoms, vaginal film, or a foam spermicide are reasonably effective, easy-to-use methods. Keep one of these backup methods handy in case you forget to take a pill, forget to buy more, or stop taking them for any reason. If you may need STD protection, condoms are a good choice.

Choose the best day of the month for starting your pills. To use a combined oral contraceptive successfully, it is vital that you take it every day around the same time, without fail, so you maintain an effective level of the hormones in your body. For this reason, you want to make your pill-taking as easy as possible to remember. You also will need to remember to buy the next pack before your supply runs out. Whichever day you choose for starting your pills from then on will be the day you begin every new pill packet. Health care providers and the manufacturers of oral contraceptives usually suggest starting your pill packet on a Sunday, or on the first day of your menstrual period. Read the package insert for instructions for your particular brand. If you begin your first pack of pills on a Sunday, you will start every subsequent packet on a Sunday.

Link your pill-taking to another daily activity. It will be easier to remember to take a birth control pill at the same time every day if you associate it with something you usually do without fail, such as brushing your teeth or preparing for bed. Pill packages are designed to indicate whether you have taken that day's pill.

To avoid the possibility of nausea, do not take the pill on an empty stomach. Take your pill after dinner or with a bedtime snack.

Begin the next packet of pills on time or you might ovulate—and you could become pregnant. If you are using 21-day packs and extend the pill-free interval beyond the seventh day, there is a chance you might ovulate during your next cycle. If you are using a 28-pill pack and do not start a new pack the day after you finish the old one, you also put yourself at risk of ovulating, because the last seven pills contain no active ingredients.

During the 7 hormone-free days, the other hormones in your body that stimulate ovulation gradually return to almost normal levels, enabling the ovary to function again. If you lengthen the hormone-free interval at all, by missing a pill at either end of the interval, the ovary may release a mature egg a few days after the interval. When on oral contraceptives, the highest fertility is after the hormone-free period, not at mid-month. Furthermore, the effect of the pill on the cervical mucus will be at its lowest, so adding to the hormone-free days can allow sperm to pass through the cervix.

NOTE: Missing a pill just before or just after the hormone-free interval is riskier than missing a pill in the middle of your cycle.

After the interval of no active pills or no pills at all (depending on whether you use a 28-day or 21-day pack), the first seven active pills restore the ovaries to a non-active state.

WHAT TO DO IF YOU FORGET TO TAKE A COMBINATION PILL

If you miss taking one pill, take the delayed pill at once—and continue to take the rest of the pills as usual.

If you miss two active tablets in Week One or Week Two, you should take two tablets the day you remember and two tablets the next day. Then take one tablet a day until you have finished the pack. If you have sex during the 7 days following the missing pills, use your backup method.

If you miss two active tablets in Week Three, or you miss three or more active tablets in a row, throw out the rest of the pack and start a new one the same day. Use a backup method if you have sex in the 7 days after you have missed the pills.

If you are using a 28-day pack and forget to take any nonactive pills (the last seven), throw away the missed pills and continue to finish the packet on schedule. Forgetting the non-active pills does not increase your risk of pregnancy. Be sure to start your next pack on time, however.

If you continue to forget to take your pills, this may not be the best method for you. Think hard about your temperament and lifestyle. Other contraceptive methods—like Norplant or Depo-Provera injections—may better match your particular needs.

Keep an extra package of pills on hand at all times. If you misplace your packet or forget to have your prescription refilled, you will not run the risk of missing a pill if you have a second pack. Furthermore, if you get the flu or some other illness that causes vomiting, you need to take extra pills to replace those that do not remain in your stomach.

When you start your pills dictates when you have your period. Your menstrual period will usually occur sometime during the last 7 days of a cycle—after you finish the active pills. You may bleed for only a couple of days or only have some spotting. The blood also may be brownish in color.

If you miss one menstrual period, but have taken your pills at the same time and every day, it does not mean you are pregnant. It is possible to miss a period now and then while on the Pill. If you are concerned, call your health care provider.

If you miss two menstrual periods in a row despite taking your birth control pills at the same time every day, you may be pregnant. Call your doctor or clinic for an early pregnancy test immediately.

If you do not menstruate and have forgotten to take one or more pills during that cycle, your chances of being pregnant are greater. Do not start a new pack of tablets. Instead, use another form of contraception and contact your clinic or doctor for an early pregnancy test. The early tests available today, which measure the pregnancy hormone, human chorionic gonadotropin, in the blood, can provide reliable results as early as one week after conception. The tests sold in drugstores are not sensitive enough to be positive this early.

HOW TO HANDLE SIDE EFFECTS

Vomiting or Diarrhea

Vomiting right after taking a pill prevents the hormones from being absorbed. If vomiting happens within two hours after you have swallowed a tablet, take another one as soon as you can. (If you use up all your active pills, take the pill for that day from your extra packet.) If you cannot keep a pill down for a second day, which may happen during a severe bout of flu, use your backup method until you have been back on the pills for 7 days or have had your next period. Then start a new package of pills on your usual day, even if you are bleeding. If you have severe diarrhea for more than one day, also use your backup method for the rest of the month and then begin another cycle of pills as usual.

Do not use the pill packet you have "borrowed" pills from because it will not have enough left. Save it—you may need to use it for extra pills sometime again. To avoid confusion, label it "Extra Pills."

Drug Interactions

The effectiveness of the Pill can be weakened by a number of prescription drugs. Drugs that may affect the performance of the Pill include some medications for treating tuberculosis, drugs for controlling seizures, and certain prescription drugs for headaches.

Certain classes of drugs stimulate the liver to greater activity, causing it to process other chemicals—like birth control pills—faster, diminishing their effect. Such liver-stimulating drugs include the antiseizure medicines used to treat epilepsy that contain phenylbuta-zone (Butazolidin), phenobarbital, phenytoin (Dilantin), primidone (Mysoline), and carbamazepine (Tegretol). If you must take any of these, it probably would be prudent to use a different type of birth control. The possibility of such an interaction is something to discuss with your physician and pharmacist. Newer anticonvulsants may not have this effect.

A type of barbiturate called butalbital, found in prescription headache tablets such as Fiorinal, Fioricet, Esgic, and others, also decreases the effectiveness of hormonal contraceptives. It might be wise to use backup protection if you need these painkillers for more than one day.

The tuberculosis antibiotic rifampin and oral antifungal medications containing griseofulvin (Fulvicin, Grifulvin V) could reduce the effectiveness of the Pill. Griseofulvin increases menstrual irregularities for women using oral contraceptives. You may want to use another birth control method while you are using these drugs.

Obviously, whenever a new medicine is prescribed for you, or a blood test is scheduled, you should remind your caregiver that you are taking birth control pills. It is also a good idea to remind your pharmacist. Because pharmacists are drug specialists, they may be more up-to-date on possible interactions between new drugs and the Pill.

COST

The cost of using oral contraceptives includes having a physical examination when the Pill is prescribed for the first time and at regular intervals thereafter while you continue to use this method. Physicals range from $60 to $175, plus charges for the necessary laboratory tests. The cost depends on whether you go to a government-funded clinic, a health maintenance organization (HMO), a private physician, a private health care facility, or a Planned Parenthood or other women's health center. Clinics supported by government agencies may charge a sliding fee, which usually means you pay according to your income. You can compare prices charged for the examination by telephoning health centers and doctors' offices.

The cost of filling a prescription for the Pill may range from $17 to $25 for a month's supply, depending on the type and brand of pill and the pharmacy filling the prescription. Since there are 13 menstrual cycles in each year, the expense of birth control pills for one year can range from $221 to $325. Packets of pills cost less if you buy them from large drugstore chains or from nonprofit or publicly funded clinics.

The majority of HMOs require only their usual co-payment charge ($5 to $20) for the necessary physical examination and for filling the prescription every month. In some states, birth control expenses are reimbursed in part by Medicaid. Some, but not many, conventional health insurance plans may cover the expense of oral contraceptives.

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