Progestin-only pills (POPs) are variants of the more commonly used combined (estrogen and progestin) oral contraceptives. Because POPs have no estrogen and only very small amounts of progestin, they are sometimes called "minipills." Like Depo-Provera and Norplant, POPs do not contain the estrogen thought to lead to serious cardiovascular complications, such as blood clots and thrombophlebitis. They also are thought to be safer than the combined pill for women who smoke. A POP is taken every day of the month, even during menstrual periods. It can be started as early as a week after childbirth or immediately after a miscarriage or abortion.
This birth control pill protects against pregnancy four ways: (1) Its chief impact is the thickening of the cervical mucus, thus stopping sperm from entering the uterus. (2) It suppresses ovulation in about half the women who use it. (3) It slows the movement of an egg through the fallopian tubes. (4) It causes the lining of the uterus to become inhospitable to a fertilized egg. Making the cervical mucus difficult for sperm to penetrate is the minipill's most immediate and useful effect; the other actions chiefly enhance its effectiveness.
The failure rate of the POP ranges from 0.5 percent for women who use it perfectly to 5 percent for women who sometimes take the pill late or forget it. Women who are less fertile because they are older or are breastfeeding have the least chance of pregnancy while using this pill.
With this pill, any change in the time you take it is more likely to result in a pregnancy than if you were taking a combined oral contraceptive. The POP absolutely needs to be taken at the same time every day. Its greatest effect on the cervical mucus peaks within 2-3 hours after the pill has been taken and then gradually diminishes. After 24 hours the cervical mucus has returned to almost normal. To get the greatest protection, it is best to set up your POP schedule so you take a pill a few hours before you are most likely to have intercourse (not right before), and then stick to that regimen. Some women find it easy to remember to take a POP because it is a daily event.
Minipill effectiveness may also depend on the dose, since the amount of the progestin in the available brands may not be enough for some women, particularly very large women. In several studies, pregnancies occurred most often among women who weighed over 155 pounds.
NOTE: Like combined oral contraceptives, progestin-only pills do not offer any protection against AIDS and other sexually transmitted diseases. Male condoms with spermicide offer the best protection against bacteria and viruses. Abstinence or a long-term, mutually faithful relationship are the only other truly effective ways to protect yourself.
IN A NUTSHELL
Progestin-only pills (POPs) are birth control pills that contain only one hormone, a progestin, instead of two. They are not as likely to cause side effects such as nausea or breast tenderness. Women who take them may also have less risk of serious side effects like blood clots and strokes. POPs also can be taken by women who are breastfeeding.
POPs are likely to cause changes in your periods. You may have irregular periods, light periods, or none at all.
Because this type of Pill has only one hormone, it must be taken at exactly the same time every day. ANY CHANGE in the time you take this pill will reduce its protection. If you have a hard time sticking to a strict schedule, POPs may not be the right birth control for you.
To get a prescription for progestin-only pills, you must be examined by your doctor or nurse. There are only three brands of POPs. Not all drugstores sell all three, but most will order them for you.
Progestin-only birth control pills do not protect you against any STDs, including AIDS.
Women who stop using the POP appear to return to their normal fertility much more quickly than women who use the combination pills. When a woman has difficulty conceiving after going off POPs, the reasons often are her age, a physical condition that existed before she started the pill, or an unrelated condition that developed during the time she was taking it.
Because so few women use progestin-only pills, there have not been any large studies to demonstrate particular health benefits or disadvantages. They are thought to be safer, at least in theory, than estrogen-containing oral contraceptives, while providing many of the same benefits.
Because they contain no estrogen, progestin-only pills cause fewer serious complications and side effects than combined oral contraceptives. If you have a cardiovascular health problem that does not allow you to use a combined oral contraceptive, you may do well on POPs. If you developed high blood pressure or headaches while taking the combined pill, POPs may be a better oral contraceptive for you.
Minipills have not been found to increase the risk of cancers, and they are less likely to cause some of the side effects seen with combined pills, such as depression, nausea, breast tenderness, acne, and unwanted hair growth. They may be a good choice if you are diabetic. The minipill is also useful if you want to breastfeed and to use an oral contraceptive. It is best, however, to start using POPs after breastfeeding is well established. (See Chapter 17 for information on breastfeeding and contraceptive use.)
Most of the health benefits of progestin-only pills are similar to those of combined oral contraceptives: a decrease in menstrual cramps or pain, less heavy bleeding, and a lessening of premenstrual syndrome (PMS) symptoms.
Functional Ovarian Cysts. As we explained in Chapter 7, during the menstrual cycle some follicles in the ovaries do not rupture or disappear as they normally would, but enlarge and become cysts instead. Although these cysts rarely produce symptoms, some may cause pelvic pain, pain during intercourse, or unusually heavy or painful periods. Women using progestin-only pills are at a slightly greater than average risk of developing this problem. If the cysts cause symptoms, your health care provider may recommend that you use another contraceptive method. Most cysts disappear in a few months without treatment.
Ectopic Pregnancy. If pregnancy does occur when you are using the minipill, your risk of having an ectopic (tubal) pregnancy is somewhat higher than usual. A possible explanation is that the minipill does not always stop ovulation, but can slow the transport of the egg through the fallopian tubes. Symptoms of an ectopic pregnancy include sudden abdominal pain and unexpected vaginal spotting or bleeding.
Breast Cancer. There appears to be no greater risk of breast cancer among women who use progestin-only contraceptives. If you already have breast cancer, however, you should not use any oral contraceptive.
Menstrual Disturbances. Expect to experience changes in your menstrual periods when you start taking the minipill. If ovulation stops, you will be completely protected against pregnancy and you probably will have very irregular periods or none at all. If you continue to have regular periods, you are probably still ovulating, at least some of the time. You will need to be careful in your use of the POP and in using backup contraception if you miss a pill or take one late.
Erratic bleeding patterns are the most notable side effect, common to all progestin-only methods, including the minipill. It is not unusual to have periods of light bleeding that last longer or are spaced closer together. Sometimes menstrual periods are fairly regular, but there is breakthrough bleeding between them. Shortened cycles are common. Long episodes of bleeding or no bleeding at all happen less often. Many women will have less bleeding overall, which means they are less likely to be anemic.
Although menstruation that is unpredictable or more frequent is annoying, it is not a health problem. The frequency of short cycles seems to decrease with time. If you continue to find your menstrual changes annoying, talk to your health care provider about switching methods.
However, if you stop having periods after you have already been on the minipill for some time, it could be an indication of pregnancy, and you should talk immediately to your health care provider about a pregnancy test. Also consult your provider if you experience prolonged episodes of bleeding or have severe abdominal pain.
Effect on the Fetus. 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.
Drug Interactions. POPs can be made less effective by some commonly prescribed drugs that speed up liver activity, which may lead to breakthrough bleeding or even pregnancy, although this occurs rarely. Drugs that may affect the performance of the minipill include prescription headache pills containing barbiturates such as butalbital (Fiorinal, Fioricet, Esgic), the tuberculosis antibiotic rifampin, the oral antifungal drug griseofulvin (Fulvicin, Grifulvin, Grisactin), and antiseizure drugs containing carbamazepine (Tegretol), phenytoin (Dilantin), primidone (Mysoline), or phenobarbital. If you take such medications regularly, progestin-only pills are not recommended. New antiseizure drugs like Neurontin and Lamictal may be less likely to interact with birth control pills.
Whenever a drug is prescribed for you, remind your medical provider of the other medications you are using. It is a good idea to remind your pharmacist also.
Breastfeeding. Unlike contraceptives that contain estrogen, proges-tin-only pills do not reduce the amount of breast milk. A small amount of the hormone does get into breast milk, however, although this has not been found to have a negative effect on babies. If you strongly prefer birth control pills over other methods of contraception, the progestin-only pill is the best choice while you nurse your baby.
If you do not breastfeed or if you nurse but also give your baby supplementary foods, you should begin taking the minipill soon after delivery, because you will begin ovulating again. For convenience, you may want to ask your health care provider for a POP prescription before the birth or soon after. When you stop breastfeeding, you can either continue with the progestin-only pill or you can switch to the combined pill. Breastfeeding women who are fully nursing and whose periods have not started can delay the use of other contraceptive methods for a while. Information on breastfeeding and contraception is given in Chapter 17.
To determine if a you are a good candidate for the minipill, a personal and family health history is taken by a health care provider. A physical examination, including a pelvic exam and a Pap test, is also necessary.
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.
Progestin-only pills rely on a very low dose of a single hormone. To maintain their impact on the cervical mucus, POPs must be taken every day, at the same time each day. This is unlike combined oral contraceptives, most of which have a 7-day drug-free interval. (Some versions of the Pill are taken every day but the last week of pills are nonactive.) The effects of the minipill last for barely 24 hours before they wear off. As we noted, the greatest impact on the cervical mucus is achieved within 2 to 3 hours after you have swallowed the pill.
The kinds of errors that threaten the minipill's effectiveness include: (1) taking a pill more than 3 hours late, (2) forgetting to take a pill for 1 day or more, and (3) not using a backup method when a pill is taken late, missed, vomited up, or taken with medicine that weakens its potency.
Start the pill on the first day of your period. Take one pill each day until you have finished the packet; then start a new packet the very next day. With the minipill you must never skip a day. Your pharmacy will probably let you buy two packets at the beginning, or you can ask your doctor to write the prescription for two packets rather than one. When you finish the first pack, buy another. This way you will always have a package of pills in reserve.
Use a backup method of birth control for the first 7 days. It will take at least a week for the pill to achieve its several effects during your first cycle. To be extra safe, you may want to use your backup for the first month, to make sure you can stick to the rigid schedule the minipill method requires. Condoms, foam, a diaphragm with a spermicide, or contraceptive film are good backup choices. No methods that rely on body temperature or mucus quality (natural methods) should be used at the same time as POPs, since the hormone in the pill will change all these natural signals. Always keep a backup contraceptive handy in case you forget to refill your prescription or must discontinue POPs for some reason.
Link your pill-taking with another daily activity. Make it easy to follow your pill schedule. Women who usually have intercourse at night should schedule their pill-taking with dinner. And, if you take your pill in the evening, you will still be protected the next morning or afternoon. The fact that you must take the pill at the same time every day does not mean you can have sex only at set times. But it does make sense to be most protected when you most likely will have intercourse.
Vomiting or severe diarrhea. Your intestinal system may not absorb the progestin if you are having severe diarrhea or vomiting. If you vomit within 2 hours after taking a minipill, take another one and stay with your pill regimen. Use your backup contraceptive if you have sex while you are sick and for at least 7 days afterwards.
If you miss one minipill. If you miss taking a pill, take the pill you missed as soon as you remember. Also take the next pill at the regular time even if it means taking two pills in one day. If you are more than 3 hours late taking the minipill, also use your backup method for 7 days when you have sex.
If you miss two or more minipills in a row. Miss taking two or more pills in a row, and you could become pregnant. Start using your backup method right away. Take two pills every day until you have used up the pills you have missed. Continue to use your backup method for 7 days beyond the day your pill-taking went back on schedule.
Lighter and shorter periods. You may bleed for only a couple of days, or only have some spotting. The blood may be brownish in
ARE YOU A GOOD CANDIDATE FOR POPs?
If you tend to be disorganized or forgetful or if your daily routine is unpredictable, you may find that the rigid pill-taking schedule necessary with the progestin-only pill may not work for you. There is very little margin of error with this method. Even a minor delay in pill-taking can make you susceptible to pregnancy.
If you are breastfeeding or over age 35, it is likely that your fertility is diminished. The minipill can be a good choice for you—if your lifestyle allows you stick to a schedule.
color. Your periods may become shorter or very irregular. For example, you may have a 28-day cycle, followed by a 17-day cycle, followed by a 35-day cycle. Some of these irregularities may correct themselves after a few months; some may not. None of these changes is medically important.
Breakthrough bleeding. If you have breakthrough spotting or bleeding between your menstrual periods, continue to take your pills on schedule. In most cases, bleeding between periods stops in a few days. Breakthrough bleeding is not unusual during the first few months of taking the minipill. It may occur if you have missed one or more pills. If it continues beyond the first 4 or 5 months, see your health care practitioner.
Heavy bleeding and cramps. If the bleeding is uncommonly heavy for you, or if you have unusual cramps, pain, or fever, see your practitioner. These can be signs of an ectopic pregnancy or infection.
If your period is overdue but you have not forgotten any pills, it does not mean you are pregnant. It is not remarkable to miss a period occasionally while taking progestin-only pills. If you are worried about being pregnant, contact your health care provider.
If you miss a period and have forgotten one or more minipills during that cycle, particularly early in the cycle, there is a chance that you are pregnant. Contact your clinic or doctor for an early pregnancy test. A blood pregnancy test (one that uses a blood sample) can be accurate approximately 1 week after conception. A urine pregnancy test is accurate 10 to 14 days after the missed period, or about 4 weeks after conception. Home pregnancy tests are accurate only if the directions on the package are followed carefully. If used too early, they may give a false negative result.
Keep a record of your periods. If 45 days have passed since the beginning of your last menstrual period and you suspect you may be pregnant, call your doctor or clinic to arrange for an early pregnancy test. This is especially important if you have been sick or have missed more than one pill without using your backup method of birth control.
If your pregnancy test is negative, discuss with your health care provider whether you should have a second test, especially if you have symptoms like morning sickness or enlarged breasts that are signs of pregnancy.
The expense of using any oral contraceptive, including the minipill, includes a physical examination and perhaps laboratory tests. Physicals can range in cost from $60 to $175, plus charges for the tests. The amount depends on whether you go to a private physician or health care center, a government-funded clinic, or to Planned Parenthood or another nonprofit women's health care center. Some government-funded clinics charge a sliding fee, which generally means you pay according to your income. If you belong to an HMO, the cost is the usual modest co-payment for the physical and for filling the prescription every month. Some, but not many, commercial insurance plans also cover the expense of minipill prescriptions—check your plan.
The price of minipills ranges from $26 to just over $30 for a month's supply, depending on the pharmacy filling the prescription. Not all drugstores carry all three brands of minipills, although they
Micronor 28-day pack or dispenser Ortho
Ovrette 6 dispensers/28 tablets each Wyeth-Ayerst are usually willing to order them. Because even a modest variation in cost adds up over the months, it is worth shopping around for the lowest price. As usual, minipills cost less at women's health centers, Planned Parenthood, public clinics, and large chain drugstores.
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