The Combined Oral Contraceptive Pill
I recently visited my daughter at college. I walked into the bathroom of her house she shares with 5 other women and was shocked to find a pack of combined oral contraceptive pills with several active pills scattered throughout the pack. I walked out of the bathroom and held up the pack. I first asked if the person using that pill was on it for contraception or cycle control or another medical indication. To my relief, the woman uses it for cycle control. What followed was a robust question and answer session around combined oral contraception after which I was amazed at the lack of information these women had around “the pill”. I asked if I could have her permission to share what I found in a blog and a reel. Thank you to her for the inspiration that led to this post.
The combined oral contraceptive pill (“the pill”) has revolutionized reproductive health since its approval by the FDA in 1960. It was initially approved for contraception, but is now used for suppression of menstruation for people who have polycystic ovarian syndrome (PCOS), painful periods, menstrual migraines, endometriosis, prevention of painful ovarian cysts, acne, or pain with ovulation. It comes in two types: monophasic and triphasic. Monophasic pills have the exact same dose of medication daily for 21 to 24 days, or if it is an “extended dose” pack it is 84 days of active medication. A triphasic pill has a different dose of estrogen and progesterone each week over three weeks the fourth week is a placebo (no hormones). This mimics the menstrual cycle more than a monophasic pill.
The pill is a very common medication that is prescribed by gynecologists, family practitioners, pediatricians and primary care physicians and providers. However, in the limited time that we have with our patients we don’t always adequately explain how to take the pill and how to navigate and troubleshoot medication mishaps. This results in calls to family and friends that have been taking something similar but have no medical knowledge or a trip to “Dr. Google”. I hope to answer some of the “what to do if...” questions here.
Common Error Number One: Taking a tricyclic pill continuously for period suppression.
For years gynecologists would take the pill and skip the placebo and thus skip their period. Women would do this for special occasions, or just because they didn’t want to get their period. This caught on, and some pharmaceutical companies now package an “extended dose” pill pack that has 84 active pills in each pack. This is very safe and effective, but cannot not be done with all types of hormonal birth control pills; if you try this with a tricyclic pill you may have irregular bleeding. Because the dose of the triphasic pill changes every week it is common to have breakthrough bleeding if you skip your placebo when you are on this formulation. Your uterine lining responds to fluctuation in hormone levels to determine when it needs to clean house:when you shed your lining and bleed. You CAN take a monophasic pill continuously because the amount of hormone in every dose is the same, thus there is no signal to build and then shed the uterine lining.
Common Error Number Two: How to trouble shoot a missed dose.
This was the strategy taken in the pill pack shown in the reel and the picture included in the blog (I love a good visual aid). If you forget a pill and you are on combined oral contraception, take it when you remember. If that is when you are due for your next pill then take the forgotten pill and the current dose together. This can result in some irregular vaginal bleeding, and occasionally nausea from doubling the hormones but it is temporary. If you are using the pill for contraception and this happens more than twice in a pack, then use backup contraception with condoms, spermicide, or the sponge. If you are taking the pill continuously (daily without taking the placebo) it is fine to take them from different packs as long as the actual medication is the same dose. For example, I have some college age patients who keep a pack in their backpack and a pack in their bathroom because their schedules are variable. This way they have a pack available at the same time every day. If you miss a pill at the beginning or the end of a pack it may be less effective; make sure that you have at least 7 consecutive days of pills in your system before resuming unprotected penile vaginal penetration.
Common Error Number Three: Taking medications that can decrease the effectiveness of the pill.
When I started the pill, I was told that if I went on antibiotics I should use a back up form of contraception because the antibiotics would decrease the efficacy of the pill. This is NOT true. In fact, only some antibiotics that are used to treat Tuberculosis have been shown to decrease the pill’s efficacy. There are some medications that will affect metabolism of the pill, including Anti- HIV medications, some anti seizure medications, and some over the counter medications like St. John’s Wort. Most medications will include warnings regarding interactions with other medications. If you are not sure if you are taking one of these medications please talk to your doctor, prescribing provider, or your pharmacist.
Things to Ponder if Remembering Your Pill is a Problem:
You may want to try similar medication with a different route of administration that has to be changed weekly (the patch) or monthly (vaginal ring).
Long Acting Reversible Contraception (LARC) is also a great option that is available to people of all ages. Options in this category include intrauterine device (IUD) or an insert that can go under the skin in your arm. These are great if you are forgetful, travel a lot or if you are taking medications that conflict with the metabolism of the pill.
Zhanel GG, Siemens S, Slayter K, Mandell L. Antibiotic and oral contraceptive drug interactions: Is there a need for concern? Can J Infect Dis. 1999 Nov;10(6):429-33. doi: 10.1155/1999/539376. PMID: 22346401; PMCID: PMC3250726.
2024 U.S. Selected Practice Recommendations for Contraceptive Use