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 progesterone only pill.

Most women are very happy being on the pill, both in terms of contraception and having regulated light periods. 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 progesterone (monophasic) and some vary during the cycle. There are different ratios of oestrogen to progesterone in various pills as well as different forms of oestrogen and progesterone. 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 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 may also benefit from a lower dose of oestrogen.

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

Newer forms of progesterone 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 progesterone 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 friend’s recommendation.

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 progesterone of the lower DVT risk.

Contraceptive pill types

Type of preparationOestrogen contentProgestogen contentTablets per cycleBrandClinical comments
Monophasic low strengthEthinylestradiol 20 microgramsDesogestrel 150 micrograms21Gedarel 20/150
Low oestrogen may be less effective, used for older less fertile women with oestrogen side effects e.g nausea, breast tenderness or classical migraine during active pills. Monophasic pills may have less side effects as there are less changes in hormones level.
Gestodene 75 micrograms21Femodette
Millinette 20/75
Sunya 20/75
Norethisterone acetate 1mg21Loestrin 20
Drospirenone 3mg21Daylette
Monophasic standard strengthEthinylestradiol 30 microgramsDesogestrel 150 micrograms21Gedarel 30/150
These 3 newer (3rd generation) progesterones may improve spots and oily skin.
Drospirenone 3mg21Yasmin
Gestodene 75 micrograms21Femodene
Katya 30/75
Millinette 30/75
Levonorgestrel 150 micrograms21Levest
Microgynon 30
Older progesterones have lower risk of deep vein thrombosis (DVT).
Norethisterone acetate 1.5mg21Loestrin 30
Ethinylestradiol 35 microgramsNorgestimate 250 micrograms21Cilest
Norethisterone 500 micrograms21Brevinor
Norethisterone 1mg21Norimin
Mestranol 50 microgramsNorethisterone 1mg21Norinyl-1
Ethinylestradiol 30 microgramsGestodene 75 micrograms21 active
7 inactive
Femodene EDEveryday preparations with inactive pills can be useful if remembering to start taking pills again after pill free interval is a problem.
Levonorgestrel 150 micrograms21 active
7 inactive
Microgynon 30 ED
Estradiol (as hemihydrate) 1.5mgNomegestrol acetate 2.5mg24 active
4 inactive
Biphasic COCEthinylestradiol 35 microgramsNorethisterone 500 micrograms7BiNovum (discontinued)The progesterone dose is increased about halfway through the cycle, more closely mimicking a natural cycle.
Norethisterone 1mg14
Triphasic standardEthinylestradiol 30 microgramsGestodene 50 micrograms6TriadeneTriphasic pills increase the dose of oestrogen and progesterone through the cycle, some of the oestrogen drops at the end.
Ethinylestradiol 40 microgramsGestodene 70 micrograms4
Ethinylestradiol 30 microgramsGestodene 100 micrograms10
Ethinylestradiol 30 microgramsLevonorgestrel 50 micrograms6Logynon
Ethinylestradiol 40 microgramsLevonorgestrel 75 micrograms5
Ethinylestradiol 40 microgramsLevonorgestrel 125 micrograms10
Ethinylestradiol 35 microgramsNorethisterone 500 micrograms7Synphase
Norethisterone 1mg9
Norethisterone 500 micrograms5
Ethinylestradiol 35 microgramsNorethisterone 500 micrograms7TriNovum
Norethisterone 750 micrograms7
Norethisterone 1mg7
Ethinylestradiol 30 microgramsLevonorgestrel 50 micrograms6 activeLogynon ED
Ethinylestradiol 40 microgramsLevonorgestrel 75 micrograms5 active
Ethinylestradiol 30 microgramsLevonorgestrel 125 micrograms10 active
7 inactive
QuadraphasicEstradiol valerate 3mgDienogest 2mg2 activeQlairaCan help with heavy withdrawal or breakthrough bleeding.
The number of different coloured pill could be confusing and lead to pill taking error.
Estradiol valerate 2mg5 active
Estradiol valerate 2mgDienogest 3mg17 active
Estradiol valerate 1mg2 active
2 inactive

Contraceptive pills