If you’ve decided that taking a combined pill is what you want to do, you need to know which one is best. You may wish to read up on what the pill is doing to your body, the pros and cons, or how to check if it suits your lifestyle; if you haven’t already.
Figuring out which one is best can seem confusing as hell. And it doesn’t help that health care providers are often a little confused about it all too.
The choices you face are:
- Ingredients – which type of fake hormones
- Dosage – the strength of those fake hormones
- Regime – the pattern to which you take your pills (eg every day, or 21 days on and 7 days off, etc)
This post is about combined pills – they use synthetic estrogen and synthetic progestin
how much fake estrogen do you want?
Most combined pills use ethinyl estradiol (this is the fake estrogen). The lowest dose of 20mcg is associated with the fewest major adverse events such as blood clots, as well as fewer headaches, less boob pain and less bloating.
However, this low dose could result in more breakthrough bleeding or spotting. If you experience too much inconvenient bleeding and want to go up a dose the next stage would normally be 30-35mcg. Going up to 50mcg is not advisable due to safety concerns.
With combined pills, as with most hormonal contraceptives, the main concern is the risk of blood clots (more specifically venous thromboembolism – or VTE – the formation of blood clots in a vein). There are many other health concerns of course, but none that can sneak up on you quite so suddenly.
In terms of risk of VTE; the lower the estrogen dose the better, but the newer generation progestins give a higher risk of VTE regardless of the estrogen dose.
important notes on dose
- As with all medication – you want to use as low a dose as possible whilst still getting the effect, so that the disruptions or side effects you experience are minimal. With hormonal contraceptives though this is slightly misleading – no matter how low the dose you are still completely disrupting your hormonal cycle. So whilst you can have lower doses, do not be fooled into thinking these are having ‘low’ impact on your body.
- The bigger you are; the higher dose you may need. Women with highest body weight have been found to have the highest failure rate (pregnancy). Discuss this with your doctor.
what about the progestins
These can be split into ‘old’ vs ‘new’ (first & second generation vs third & fourth generation)
The newer generation progestins were created with the hope of causing fewer undesirable symptoms. In general, they tend to be less androgenic, meaning they should cause less weight gain, unwanted hair growth and acne than the older types. However these benefits may be marginal and the evidence is fairly scarce. What is certain is that they increase the risk of VTE; to roughly 40 cases in every 100,000 women per year (the risk with older progestins is half of this)
Bayer are the company that make Yaz and Yasmin (containing drospirenone – new generation progestin). In the US there have been over 13,000 cases filed against them for the harm caused by these pills, and there have been at least 100 alleged deaths. Bayer are accused of presenting misleading data about the real health risks of these pills. They have paid out over $1.6 billion in settlements, whilst still purporting that they have done nothing wrong.
Levonorgestrel: Includes Microgynon, Rigevidon, Logynon, Seasonale
The most widely prescribed contraceptive progestin worldwide. Tends to be more androgenic than the other common second generation progestins.
Norethindrone acetate is also commonly prescribed: Includes Loestrin
Norgestimate: Includes Cilest, Ortho Cyclen
Overall a slightly higher VTE risk than the second generation progestins, but lower risk than the other common third/fourth generation progestins (Norgestimate is sometimes classified as second generation).
Desogestrel: Includes Cerazette, Marvelon, Mercilon
Gestodene: Includes Femodette
Drospirenone: Includes Yasmin, Yaz
Fewer symptoms related to water retention, and greater improvement in acne compared to levonorgestrel (second generation). Drospirenone may cause higher potassium levels, so women with kidney, liver, or adrenal disease are advised not to use it.
The above image is a rough guide to side effects you may experience for different types of pill.
Pills that lead to more estrogenic pregnancy-like side effects, such as water retention/bloating, are on the left. These may not affect your skin or hair as much though.
Those on the right hand side have more progesterone heavy side effects, like PMT symptoms, such as drop in libido, low mood, and skin break outs.
The older ones are on the right and the newer ones on the left. The chart is to give an overall estimation of what side effects you experience, but does not account for safety.
Anything like this is very general, for example drospirenone is actually said to reduce estrogenic effects like bloating and breast tenderness. You might be tempted to conclude that the medical world is still trying to figure out exactly what birth control does.
A recent large scale study has found that the combination of levonorgestrel (an old generation progestin) with 20mcg of estrogen is associated with the lowest incidence of serious adverse events (pills such as Lybrel, Alesse and Levlite). In other words these pills result in fewest hospital admissions compared with all other types of combined pills.
what about phases?
Aside from the standard one phase pill types; you can get some that are multiphasic – meaning the pills contain varying doses of hormones throughout the month (such as Kariva or Cyclessa). This is an attempt to reduce side effects and unwanted withdrawal bleeds. There is little evidence to suggest that adjusting the phases achieves any real benefits.
Multi-phase pills have different doses; so you have to take them in the correct order throughout the month. If you get this wrong they may not be as effective. Fiddling around with phases might be a bit pointless.
what about regimes?
The other, more noteworthy, variable is the regime. The standard regime is 21 days on/7 days off, but there are also extended regimes, such as 24 days on/4 days off, or even 84 days in a row. Or you could take standard pill packets back to back and omit the breaks.
Studies indicate that although there may be some slight advantages; a slight decrease in negative symptoms and perhaps less breakthrough bleeding, these are not massively significant. Furthermore, the accumulative dose of hormones you ingest will usually be higher overall because you are having fewer or shorter pill breaks.
The main advantage of extended regimes is that you have fewer withdrawal bleeds. Although many women like to have a monthly bleed to feel reassured that they are not pregnant; the bleeds you experience on the pill are not real periods and aren’t even necessarily a surefire sign that you’re not pregnant.
which pill is the right one for you then?
It depends. Because although safety would seem the obvious priority for many; the risk factors are fairly small and so it is up to the individual to assess how much they are willing to risk in order to have some fuss free sex.
There is unfortunately no magic formula for finding out which pill is going to give you the best skin and the biggest tits, without killing off your sex drive or turning you insane.
Your best bet is to go to your prescriber, armed with knowledge and questions, then take the plunge.
but before you do that, ask yourself, are you comfortable taking a powerful drug every day that you know is not good for you, just to save you and your partner a bit of hassle in your sex life?
You may also like The Big List of Possible Side Effects from Combined Hormonal Contraceptives.