How one doctor recommends a contraceptive pill

Photo of boxes of different brands of contraceptive pillsIn the UK, nearly a quarter of women aged 16–49 are regular pill users – it’s a popular form of contraception.

There are many pills available and all are very effective. Combined oral contraceptive (COC) pills are over 99% effective and the progesterone only pill (POP) or ‘mini pill‘ is 97% effective – so which one is right for you?

My first consideration is one of practicality. Pills must be taken regularly. For those who work shifts, live between more than one place, are chaotic or prone to forgetfulness, the pill may not be reliable. The COC has more leeway regards missed pills as well as being more effective than the POP, so is usually chosen unless there are specific reasons not to.

To me, safety is the most important issue. Some women have medical conditions that can be worsened or triggered by the hormones in the pill. This is why your doctor or nurse will go through your medical history, and that of your close family. Your current medications, including over the counter herbal ones, will be looked at. Specifically, you will be asked about migraine, smoking, blood clotting issues including clots on the leg (both you and your relatives), as well as other conditions such as diabetes, cardiovascular disease, liver problems, Raynaud’s disease, and systemic lupus erythematosus. Your blood pressure will be measured, and your weight checked, and your age considered into this complicated equation. Presence of the above conditions (severity and number of them) determines whether and sometimes which pill is suitable.

If there are none of these potentially serious health issues restricting choice, then any pill can be prescribed. There are combined oral contraceptive pills which contain both oestrogen and progestogen, as well as the mini or progestogen only pill.

Most women are very happy being on the pill, both in terms of contraception and having regulated light periods or none at all. Some women experience side effects. It is not always possible to predict who this may be (and therefore some women will go on to change their pill).

Some COCs contain a fixed ratio of oestrogen to progestogen (monophasic) and some vary during the cycle. There are different ratios of oestrogen to progestogen in various pills as well as different forms of oestrogen and progestogen. These effect the side effect profile of each pill; some ratios are more likely to cause certain effects. The effects and (if experienced – most don’t!) side effects are predictable from the contents of the pill.

The oestrogen in the combined pill controls periods better, break-through bleeding or irregular periods that are more likely in lower oestrogen pills or in the POP. Conversely, oestrogen induced nausea or headaches are less likely in lower oestrogen pills or in the POP. Breast tenderness sufferers may also benefit from a lower dose of oestrogen.

Some forms of progestogen are more likely to cause oilier skin and spots (so wouldn’t be used in someone with acne).

Newer forms of progestogen have a greater risk than others of causing deep vein thrombosis (DVT), clots on the legs.

There is less evidence regarding effect of the pill on mood. Lifestyle and other factors need to be explored if mood disturbances occur. Changing the progestogen component to a newer form may help.

Weight gain cannot be attributed to the pill. Exploring lifestyle and other factors is worthwhile, changing the pill is not. Other methods of contraception may be considered.

Some women may have a preference regarding pill brand; through previous own experience or friends’ recommendations.

Back to the original question, if none of these factors are present, as a starting point I prescribe a simple, inexpensive, monophasic pill, with a progestogen of the lower DVT risk.

Contraceptive pill types

Type of preparation Oestrogen content Progestogen content Tablets per cycle Brand Clinical comments
Monophasic low strength Ethinylestradiol 20 micrograms Desogestrel 150 micrograms 21 Gedarel 20/150
Low oestrogen often useful for perimenopausal women or those with oestrogen side effects e.g nausea, breast tenderness or headache. Monophasic pills may have less side effects as there are less changes in hormone levels but increased risk of breakthrough bleeding.
Gestodene 75 micrograms 21 Femodette
Millinette 20/75
Sunya 20/75
Norethisterone acetate 1mg 21 Loestrin 20
Drospirenone 3mg 21 Daylette
Monophasic standard strength Ethinylestradiol 30 micrograms Desogestrel 150 micrograms 21 Gedarel 30/150
These 3 newer (3rd generation) progestogens may improve spots and oily skin.
Drospirenone 3mg 21 Yasmin
Gestodene 75 micrograms 21 Femodene
Katya 30/75
Millinette 30/75
Levonorgestrel 150 micrograms 21 Levest
Microgynon 30
Older progestogens have lower risk of deep vein thrombosis (DVT).
Norethisterone acetate 1.5mg 21 Loestrin 30
Ethinylestradiol 35 micrograms Norgestimate 250 micrograms 21 Cilest
Norethisterone 500 micrograms 21 Brevinor
Norethisterone 1mg 21 Norimin
Mestranol 50 micrograms Norethisterone 1mg 21 Norinyl-1
Ethinylestradiol 30 micrograms Gestodene 75 micrograms 21 active
7 inactive
Femodene ED Everyday preparations with inactive pills can be useful if remembering to start taking pills again after pill free interval is a problem.
Levonorgestrel 150 micrograms 21 active
7 inactive
Microgynon 30 ED
Estradiol (as hemihydrate) 1.5mg Nomegestrol acetate 2.5mg 24 active
4 inactive
Biphasic COC Ethinylestradiol 35 micrograms Norethisterone 500 micrograms 7 BiNovum (discontinued) The progestogen dose is increased about halfway through the cycle, more closely mimicking a natural cycle.
Norethisterone 1mg 14
Triphasic standard Ethinylestradiol 30 micrograms Gestodene 50 micrograms 6 Triadene Triphasic pills increase the dose of oestrogen and progestogen through the cycle, some of the oestrogen drops at the end.
Ethinylestradiol 40 micrograms Gestodene 70 micrograms 4
Ethinylestradiol 30 micrograms Gestodene 100 micrograms 10
Ethinylestradiol 30 micrograms Levonorgestrel 50 micrograms 6 Logynon
Ethinylestradiol 40 micrograms Levonorgestrel 75 micrograms 5
Ethinylestradiol 40 micrograms Levonorgestrel 125 micrograms 10
Ethinylestradiol 35 micrograms Norethisterone 500 micrograms 7 Synphase
Norethisterone 1mg 9
Norethisterone 500 micrograms 5
Ethinylestradiol 35 micrograms Norethisterone 500 micrograms 7 TriNovum
Norethisterone 750 micrograms 7
Norethisterone 1mg 7
Ethinylestradiol 30 micrograms Levonorgestrel 50 micrograms 6 active Logynon ED
Ethinylestradiol 40 micrograms Levonorgestrel 75 micrograms 5 active
Ethinylestradiol 30 micrograms Levonorgestrel 125 micrograms 10 active
7 inactive
Quadraphasic Estradiol valerate 3mg Dienogest 2mg 2 active Qlaira Can help with heavy withdrawal or breakthrough bleeding.
The number of different coloured pill could be confusing and lead to pill taking error.
Estradiol valerate 2mg 5 active
Estradiol valerate 2mg Dienogest 3mg 17 active
Estradiol valerate 1mg 2 active
2 inactive

Up to date guidance is available from MIMS – Table: Contraceptives