What’s New in Oral Contraception? (Birth Control Pills)

Low-Dose, Generic, Extended-cycle–which pill is best?

Since they became available in the 1960s, birth control pills have contained a combination of progestin and estrogen. The progestin prevents ovulation and the estrogen suppresses irregular bleeding. The early pills contained a very large dose of estrogen, 150 micrograms (mcg). As you can imagine, large estrogen doses caused side effects like nausea, headache, weight gain, breast tenderness, etc. Over the years since then, the pill’s estrogen dose has gradually been reduced. Birth control pills marketed today contain 35 to as low as 10 mcg of estrogen.

All pills on the market provide effective birth control when taken as directed. When prescribing your pill, we suggest the lowest level of estrogen you are able to tolerate without experiencing irregular bleeding. We also consider your preference for generic or name brand pills.

For decades, nearly all birth control pills provided a standard 21/7 hormonal regimen. A pack of pills contained 21 active pills and 7 placebos (pills containing no hormone). The 21/7 schedule had no specific medical advantage. It was chosen merely to mimic a woman’s average menstrual cycle. In other words, taking a break each month from the hormone-containing pills would cause breakthrough bleeding similar to a woman’s normal cycle. This is NOT a period since the ovary has NOT released an egg. It was thought that a woman would feel more “normal” if she experienced monthly bleeding. The 21/7 cycle also provided monthly reassurance that one was, in fact, NOT PREGNANT.

The 21/7 schedule has a major disadvantage. We know that taking away the hormone for a few days each month occasionally produces undesirable symptoms. Some women experience PMS-type hormone withdrawal symptoms like cramping, bloating, headache, breast tenderness, or pelvic pain.

The artificial period is unnecessary and sometimes undesirable. But research indicates that most women still prefer to have a “period” at least a few times per year.

So What’s New?

We have recognized over the last few years that alternatives exist. For women who prefer the reassurance of monthly bleeding, we can shorten the hormone-free period to only four days. The 24/4 regimen contains more active pills and fewer blank pills. Women seem to tolerate the 24/4 regimen with fewer side effects.  Presently cost issues influence this choice, but 24/4 pills will likely be the most recommended option in the future.

For women who are not concerned about having a “period” each month, an extended regimen is available. These brands contain 84 active pills (a 3-month supply) and 7 blank or very-low estrogen pills. Both of these options produce fewer uncomfortable symptoms of estrogen withdrawal.

A woman can even choose to modify her regimen somewhat to fit the needs of her daily life. I advise my patients that they can skip their blank pills (and begin their new pack of active pills instead), if they would like to avoid breakthrough bleeding during an inconvenient time like school exams or an upcoming vacation. Occasionally, a woman will choose to avoid the hormone-free days and the resulting “period” for longer than just three months. We can discuss these options with you.

Finally, we help our patients weigh the advantages and costs of these choices.

  • Most generic brands offer the older 21/7 schedule
  • Only two generic brand exists for the 24/4 regimen
  • There are no generics for the ultra-low dose pill containing only 10 mcg of estrogen

Women often ask whether the generic pill is “as good” as the brand name birth control pill. Both generics and brand name pills must have FDA approval. Some women prefer the name brand and feel that they can tell a difference. While this is difficult to measure, we want you to be aware of your options and choose the one you prefer.

One More Important Issue

Over five decades, we have come to trust that birth control pills are safe for most women. As always, however, you should understand the benefits and risks of any medication you are taking. Women with high blood pressure, a history of blood clots, liver disease, or women who are smokers over age 35 have a higher risk of developing dangerous blood clots. (Blood clots are a possible risk with all birth control pills). Keep us informed of your personal and family health history. An age limit for taking the pill no longer applies to non-smoking women.