Combined Pill

It can help with some health conditions such as acne and heavy, painful periods. But there are lots of different pills – so which could be right for you?Here’s what you need to know about how it works, the different types of contraceptive pills available, potential side effects and health benefits, plus what to do if you forget to take one.

Who chooses the pill and why?

The answer is – a lot of women! Contraceptive pills are the second most popular form of birth control in the US, after female sterilization, and 12.6% of women choose it. In the UK they’re the most popular form of contraception, with 27% of women using it.

In the US, pills are more popular among younger women, with older women using it less – statistics show 19.5% of women in their 20s take it, compared with just 5% in their 40s. It’s a similar story in the UK with 39% of 18-19 year olds taking a pill, dropping to just 18% of 35-44 year olds.

Here are some of the reasons it could be so popular, according to Dr Adiele Hoffman, a Healthily expert:

• it’s one of the methods that allows a woman to take full charge of her own contraception
• it’s highly effective – if you use it perfectly, the pill’s 99% effective at preventing pregnancy, meaning only 1 in 100 women taking it will get pregnant in a year, although a lot of people don’t use it perfectly all the time, which means its effectiveness drops to 91%
• the pill’s been around a long time, so it’s tried and trusted, and that may mean a lot of people feel confident using it
• it’s relatively simple and convenient to take a pill every day – you’ll usually still have reviews with your doctor to check your blood pressure and for any side effects
• there are different brands and formulas so you can work with your doctor to find one that’s right for you
• if you and your partner have been tested for STIs and are clear, it’s a kind of contraception that doesn’t interrupt the moment when you’re having sex, but it doesn’t protect against STIs

How does the pill work?

It prevents pregnancy by:

• stopping your ovaries from releasing an egg each month (ovulation)
• making the mucus in the neck of your womb thicker, so it’s harder for sperm to get into your womb and reach an egg
• thinning the lining of your womb, so if an egg did get released and fertilized, there would be less chance of it implanting and growing

How do you know the pill is the best option for you?

“Getting all the facts into a discussion with your doctor and reading information like this is important,” says Dr Adiele. “Make sure you know about the full range of contraceptives that may suit you, including some that are more effective, like the IUD and contraceptive implant. And discuss the pros and cons with your doctor. You may want to talk it through with a partner or see what other women have to say, too.”

Campaigners like the American College of Obstetricians and Gynaecologists have raised concerns that so many women take the pill, partly because physicians don’t offer some of the other effective contraceptives – some, like the IUD, need specialist training, and doctors may feel less confident about other methods, which makes prescribing pills simpler.

You can read up on the facts about all the latest contraception options using our guide.

What are the benefits of the pill?

If you follow the instructions that come with your pill, stick to the schedule and make sure you don’t miss a pill or take one late (see how to take the pill) it’s a great form of birth control. But the pill has some other perks that can help you manage certain health conditions.

It can make your periods lighter and less painful

The standard way to take the pill is to take one a day for 21 days, then have a pill-free break for 7 days. In this time, you normally have a bleed, like a period. The hormones in the pill make your period lighter and less painful – so if you have issues with menstrual cramps and heavy bleeding, it could be an option for you.

It can improve acne

The hormones in the combined pill can reduce acne, especially if you get breakouts around your period, or your acne is linked with polycystic ovary syndrome (PCOS). Sometimes, your primary care physician may prescribe it for acne even if you don’t need birth control – although it’s important to note it can take a few months to start making a difference, and up to a year to see the full benefits.

If you’re not in the USA

Some research has suggested one type of pill may reduce acne slightly more. In the UK and some other places, dianette – an older combined pill that contains a type of synthetic progesterone called cyproterone acetate is licenced for treating acne. As the risk of blood clots with dianette is higher than with other pills, in the UK it’s only recommended for a maximum of 3 months if you need an acne treatment – not as a contraceptive alone – and it’s not approved at all by the FDA in the US.

It can ease PMS

For some women, using the combined pill can improve PMS symptoms. Research shows that newer pills with a type of synthetic progesterone called drospirenone are most likely to help – these include pills such as Yasmin and Eloine. You may be advised to take them continuously, without a pill-free break, for the best effects.

It may reduce your risk of some conditions

the combined pill can lower your risk of cancer of the ovaries, womb and colon (bowel). One possible reason is that the pill stops you ovulating, which is thought to reduce the amount of natural estrogen you’re exposed to over the long term. More research is needed to understand the exact role estrogen plays and the difference between natural and manmade estrogen.
it may reduce your risk of fibroids, ovarian cysts and non-cancerous breast disease
it may lower your risk of pelvic inflammatory disease (PID)

Side effects of the contraceptive pill – and how to deal with them

Like any other medicine, the pill can have disadvantages as well as benefits. For most women, any side effects are fairly minor but there are some important ones to know about:

• temporary PMS-like symptoms – the pill may cause headaches, nausea, mood swings and breast tenderness that usually go away after 2-3 months
• How to deal with it: If they don’t go away, are severe or really bothering you, ask your doctor about switching to a different brand. If you’re getting these side effects in your hormone free week, ask about a more continuous regime
• breakthrough bleeding and spotting – usually this happens in the first few months. You don’t need to worry that this means you won’t be protected – as long as you’re taking your pills correctly, you’re fine
• How to deal with it: Breakthrough bleeding can be inconvenient and annoying. If it doesn’t settle, speak to your doctor
• raised blood pressure – birth control containing estrogen – including the combined pill – can raise your blood pressure.
• How to deal with it: Check with your doctor. If you already have high blood pressure, it may not be safe for you to take the pill but there are other contraceptive options. Blood pressure checks will be part of your regular reviews

Who shouldn’t take the pill?

If you have certain serious conditions, or you’re at high risk of any of them, your doctor will probably tell you that you should use a different kind of birth control.
“If you can’t take the combined pill, remember there are lots of other very effective contraception options that will be safe and effective for you,” says Dr Adiele.

Your doctor will look carefully at your individual overall health before prescribing the pill, but as a general rule, they may not recommend it if:

• you’re over 35 and a smoker
• you’ve had breast cancer
• you’ve had blood clots, or you have an inherited blood clotting disorder
• you get migraine headaches along with aura – visual disturbances, such as seeing wavy, flashing lines
• you have high blood pressure
• you have diabetes that’s not well managed
• you have liver disease

The facts about the pill and serious health conditions

While there are some people who shouldn’t take the pill, it’s safe for most. When the pill first came out in the 1960s, it contained high doses of hormones, but newer versions contain lower doses, and for most people, risks are small.
“Most people can take the pill safely, and it’s important to remember that it’s been around for 5 decades – millions have used it without problems. Your doctor will help you weigh up the risks and options,” says Dr Adiele.

Your healthcare professional will look at your individual overall health, including your risk of any of these serious health conditions before prescribing the pill:

Blood clots

• estrogen increases levels of substances that make your blood clot – so your risk of blood clots can increase when estrogen levels are higher, including during pregnancy, and if you’re using contraception that contains estrogen, like the combined pill
• the combined pill can raise your risk of a blood clot by 3-3.5 times. But the overall number of women who have blood clots while on the pill is very small. Between 5 and 12 women out of 10,000 who take the combined pill will have a blood clot each year, compared to 2 out of 10,000 women who don’t take it
• for some, the risk is higher than average – like women who are obese or those with a history of clots (thrombosis)
• some research suggests newer pills with lower levels of estrogen, containing a type of synthetic progesterone called levonorgestrel – like microgynon – may be safest

Breast cancer

• while the pill’s been found to lower your risk of some types of cancer, it may slightly raise your risk of breast cancer compared to women who don’t take it
• but other things increase your risk of breast cancer more – such as being overweight or obese, and drinking alcohol
• when you stop taking the pill, your risk of breast cancer stops going up, and once you’ve been off it for 10 years, it has no effect on your risk

Cervical cancer

• the pill has been shown to slightly raise your risk of cervical cancer if you take it for more than 5 years, but it reduces after stopping and any increased risk has gone by 10 years after stopping
• but overall, the evidence for the link is mixed, and scientists still don’t fully understand the connection

How to take the pill

It’s important to take the pill properly for full protection against pregnancy. Follow the instructions that come with your packet – and if you have any questions about how to take the pill, ask your healthcare professional. It's important to take the pills as instructed, because missing any may make them less effective.
How you take your pill depends on what type it is:

28-day pill packs

• take one pill every day for 28 days, then start another pack
• the last 7 pills (fewer with some brands) in each pack are placebos, sometimes called “reminder” pills or dummy pills. They don’t contain any hormones but they may contain supplements including iron. They’re designed to help you keep to the routine of taking daily pills, but it doesn’t matter if you don’t take them – as long as you’ve taken the rest of the pack properly, you’re still protected
• you’ll normally have a bleed during this last week of your pill pack

21-day pill packs

• take every pill in the pack, then have a pill-free break of 7 days
• you’ll get a bleed in the pill-free week
• it’s important you take every pill in a 21-day pack because none of them are placebos
• you’ll still be protected from pregnancy in the pill-free week
• you’ll start your next pack on the same day each week. If you struggle to remember when to start it, think about setting a reminder on your phone or putting a note somewhere you’ll see it

91-day pill packs

• a new type of pill called Seasonale is designed to be taken every day – you take a pill every day for 12 weeks, then a week of dummy pills
• you’re protected from pregnancy all the time, as long as you’re taking the pills properly – even if you choose not to take the reminder pills

Tailored regimes

You can also take the combined pill as a tailored regime. This may include:

• taking the pill for 21 days and stopping for a shorter time – for example, just 4 days rather than the usual 7
• taking the pill continuously without a break
• taking the pill for more than 21 days and deciding when the break would be convenient for you

Get into a good routine

As it’s so important you remember to take your pill every day, it may be helpful to think about how you can make it a habit. Research shows it’s often helpful to add a new behaviour after something you already do every day. Think about what would work for you. You could take your pill after:

• you’ve brushed your teeth

• you’ve had your shower

• you’ve eaten breakfast
  You could also think about ways to prompt yourself. A cue is something you put in your environment to remind you to do something. Different things will work for different people, but you could try:

• putting a sticky note somewhere you’ll see it, such as on your bathroom mirror or the fridge door

• getting a medication reminder app for your phone, or setting an alarm

• if it’s safe, leaving your pill packet somewhere you’ll see it at the same time every day

Skipping your period

If you want to miss a bleed altogether, you can do that by running your pill packs together without a 7-day break. If you’re taking a 28-day pack, you skip the dummy pills and go straight to the active pills in your next pack. Some women like to have a bleed, but there’s no harm in skipping periods and you can do it for as long as you want.
The only downside is you may be more likely to get breakthrough bleeding. It could be a good option if you struggle with things like endometriosis and period pain.

Starting the pill

• you can start the pill at any point in your menstrual cycle, but depending on where you are in your cycle, you may need to use other contraception for up to 7 days – your healthcare professional will explain that to you
• if you start your first pack on the first day of your period, you’re protected straight away
• if you’ve just had a baby and you’re breastfeeding, you should wait until 6 weeks after the birth before you start taking the pill. If you’re not breastfeeding, you can usually start it on day 21 after the birth, but check with your doctor – this will mean you’re protected immediately
• if you start it later than day 21 after giving birth, you’ll need another form of contraception for 7 days
• after a miscarriage or abortion, you can start taking the pill straight away. If you start a pill pack more than 5 days later, you’ll need extra birth control – like condoms – for 7 days. Speak to your doctor for more advice

If you miss any pills

Missing a pill – which means being more than 24 hours late with it – can put you at risk of pregnancy. If you do miss one or more, the steps you take depend on how many you’ve missed, where you are in the pack, and what brand of pill you’re taking.
You should follow the advice that comes with your pill, and speak to a healthcare professional if you’re unsure. And you could also try the missed pill calculator. But as a general rule:

• if you’ve missed one pill in the pack or you’re one day late starting a new pack after your pill-free week, take the missed pill straight away – even if that means taking 2 in one day. You’re still protected. Carry on with the rest of the pack as normal
• if you’ve missed 2 or more pills, take the last pill you’ve missed straight away, even if that means taking 2 pills in one day. Leave any earlier missed pills. You need to use avoid sex or use extra contraception for 7 days after your last missed pill, as you won’t be protected during this time
• if you’ve missed 2 or more pills and there are at least 7 left in the pack, finish the pack and have your pill-free break or take the dummy pills as usual
• if you’ve missed 2 or more pills and there are fewer than 7 left, finish that pack and then start a new one straight away – don’t have a pill-free break or take dummy pills
• if you’ve had unprotected sex after missing 2 or more pills in the first week of a pack, you may need emergency contraception
• talk to your doctor and always use extra protection for 7 days to be safe if you’re in any doubt

If you vomit or have diarrhea

• it’s important to know that if you vomit within 3 hours of taking your pill, it may not yet have been absorbed into your bloodstream, and that means you might not be protected. So you should take another pill straight away, then go back to your usual schedule
• if you keep vomiting, you may need to use another form of contraception or avoid sex until you’ve taken the pill for 7 days without being sick
• severe diarrhea can also mean you haven’t absorbed the pill properly. If you have more than 6 bouts of watery diarrhea in a 24-hour period, continue taking the pill but use extra protection while you’re sick and for 2 days afterwards

If you take other medicines or supplements

The pill can be affected by other medicines you take, which can stop it working so well.
This can happen in different ways:

• medicines that increase the amount of enzymes in your body can speed up the way contraceptive hormones are processed – this means the levels in your bloodstream are too low to protect you from pregnancy. These include certain antibiotics, some drugs to treat epilepsy, and some drugs that treat HIV, and also the herbal remedy St John’s wort, which people often use to help low mood
• other medicines can interfere with the hormones in the pill, if you take them at the same time, including drugs that are used to lower levels of bile acids
• medicines that cause diarrhea as a side effect can also affect the way the pill works
• always read the instructions that come with a medicine and ask your doctor, or a pharmacist, if you’re unsure about whether a medicine will affect the pill

When to see your doctor

• you’ll need to get a prescription for the pill, whether that’s from a doctor or nurse at your doctor’s office, a Planned Parenthood center or sexual health clinic. In some US states, you can also get a prescription online, or from a pharmacist
• in the US, the combined pill is usually available at no or low cost if you have health insurance. If not, there may be some government programs that will help you access it – Planned Parenthood can advise. In the UK, it’s free on the NHS
• you’ll need regular reviews from a healthcare professional when you’re on the pill, including blood pressure checks. And contact them at any time if you have questions or concerns like irregular bleeding
• know the signs and seek urgent medical help if you notice symptoms of a blood clot, such as throbbing or cramping pain, swelling, redness and warmth in a leg or arm, sudden breathlessness, sharp pain in your chest, and a cough or coughing up any blood
• you should also see your healthcare professional if you want to change to a different type of contraception – they’ll work out which one is suitable and tell you how to switch

Your health questions answered

Can the pill cause depression?

“Studies have shown mixed results, however, large studies have found there was no impact on mood for most women. One study found women taking the combined pill were less likely to have depressive symptoms, but there were some limitations to the research. The best advice is to talk it all through with your healthcare professional – they’ll be able to look at your mental health history and work out whether the pill is suitable for you. If you’re concerned, you could keep a diary of your mood when you start the pill, and talk to your doctor if you spot any patterns.”