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 Benefits
of BCPs
BCPs provide highly reliable contraceptive protection, exceeding 99%. Even when
imperfect use (skipping an occasional pill) is considered, the BCPs are still
very effective in preventing pregnancy.
In addition to their
contraceptive benefits, the BCPs have a number of other benefits. So long as the progestin side of the BCP is strong enough to suppress ovarian function, these pills
generally:
- Cause menstrual cycles to
occur regularly and predictably
- Shorten menstrual flows
- Lighten menstrual flows
- Reduce the risk of iron
deficiency anemia
- Reduce menstrual cramps
- Eliminate painful ovulation
- Reduce premenstrual symptoms
- Reduce cyclic breast pain
- Improve acne
- Reduce the risk of ovarian
cysts
- Reduce the risk of ovarian
cancer
- Reduce the risk of uterine
cancer
- Reduce the risk of uterine
fibroid tumors
- Reduce the risk of
symptomatic endometriosis
- Reduce the risk of pelvic
inflammatory disease
- Reduce the risk of benign
breast disease
Risks of
BCPs
Aside from a number of minor, but annoying, side effects, serious risks
of BCPs are limited, for the most part, to cardiovascular problems, including
stroke, heart attack, thrombophlebitis and thromboembolism.
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These complications are very rare
among women under age 35 who are non-smokers, and the added
risk of BCPs is difficult to measure and probably insignificant.
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For non-smokers over age 35,
the increased risk of cardiovascular problems among BCP users is measurable,
but extremely small and certainly less than the risk of pregnancy.
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For smokers under age 35,
the increased risk of cardiovascular problems among BCP users is measurable,
but extremely small and certainly less than the risk of pregnancy.
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For smokers over age 35,
the increased risk of cardiovascular problems among BCP users is very
significant, and so high as to make such use ill-advised in any but the most
extraordinary circumstances.
There is also a very small, but
measurable increase in the risk of liver tumors and cysts. The incidence of
such problems in the population is so small and the added risk so marginal
that only rarely will this risk play a role in the clinical decision for or
against BCPs .
Which Pill
to Start
Pick any standard, low-dose birth control pill that is readily
available.
Most women (90%) will do well
on any low-dose BCP. A few will do well only on certain BCPs, but there
is no way to predict in advance which pill will work best for any
individual woman.
Historically, as the hormone
dose of birth control pills was lowered, the risk of serious
complications such as blood clots was also reduced. For that reason,
starting a low-dose pill (30-35 mcg of estrogen) is preferable to
starting medium dose (50 mcg) or high dose BCPs. Lowering the dose below
the 30-35 mcg dose has not, however, led to any additional clinical
benefits but has made some of the very-low-dose pills more "unforgiving"
than the standard low-dose BCPs.
Starting
the Pill
Take the first pill on the first Sunday following the beginning
of the menstrual flow.
This means that if a period
starts on a Tuesday, you should wait all the way through the week until
Sunday, and then start taking the BCPs. If the period starts on a
Saturday, then the first BCP would be taken the next day, Sunday. If the
period starts on a Sunday, take the BCPs the same day. This method is
called a "Sunday Start" and has a number of advantages. Because a fresh
pill pack is always started on Sunday, it is easier for some people to
remember. Using a "Sunday Start" means that the pill-induced periods
will usually begin early in the week (Monday or Tuesday) and will be
over before the weekend. Many women find this timing convenient and
desirable.
An alternative method ("5th Day") is
to always start the BCP pack on day #5 of the menstrual cycle. Day #1 is the
first day of flow. This method is very effective but requires counting and
recalculations each month.
When are the Pills
Effective
The pills are reasonably effective right away.
Some physicians recommend that
women use a back-up method of contraception (such as condoms) during the
first month of BCP use.This is based on the observation that BCPs
probably do not achieve their 99.9% effectiveness until after the first
month of use.
It is also true that the BCPs
are pretty effective, even starting with the first BCP. Many BCP
manufacturers suggest that the BCP is effective after 7 days of
continuous use. Even before 7 days of BCPs have been taken, considering
that phase of the menstrual cycle, pregnancy is not very likely. For
these reasons, the BCPs are probably about as effective as using a
diaphragm (~85%-95% effective) as soon as they are started. For women
seeking a higher level of protection against pregnancy (99.9%), using a
backup method of contraception during the first month of BCP use may be
considered.
Skipped a
Pill
If she just skipped one pill, she should take it as soon as she
remembers, then continue the rest of the pills at the normal time.
If she didn't remember until
the next day, take both the current day's pill and yesterday's pill
together. Then continue with the rest of the pills in the usual way.
If she's forgotten two pills or
more, stop the BCPs, wait a few days for a "withdrawal" menstrual flow,
and then restart a fresh package of BCPs 5 days after the onset of flow.
Use backup contraception during this time and for the first month after
restarting the BCPs.
History of
Migraine Headaches
A history of migraine headaches is not a contra-indication to taking
birth control pills.
Some women with migraine
headaches find they have fewer headaches while taking BCPs. This is
particularly true for those women whose headaches primarily occur with
ovulation or around the time of the menstrual flow. Other women with
migraine headaches find the BCPs have no noticeable effect on their
headache frequency or severity. These women may safely take BCPs.
Those women who experience
worsening of their migraine headaches should not be continue the same
BCP. Switching to a different pill, with different content, from a
different manufacturer, may solve the problem. If not, it will generally
be necessary to stop the BCP completely.
High
Blood Pressure
The birth control pill may be safely prescribed to women with pre-existing high
blood pressure, but it is important for many reasons that the blood pressure be
monitored and well-controlled.
BCPs occasionally aggravate
pre-existing high blood pressure. If this happens, switching to a
different pill will sometimes solve the problem. If switching fails to
resolve the problem, then usually the BCP will need to be stopped.
BCPs will rarely cause a woman
with normal blood pressure to become hypertensive. If this happens,
switching to a different pill manufacturer will often solve the problem,
but if not, the BCP is usually stopped.
Diabetes
The birth control pill may be safely taken by women with either a personal
history or family history of diabetes melitus.
Women who have diabetes often
find taking BCPs has either no effect on their diabetic control or else
improves their control. Some women find they need more insulin while
taking BCPs, but are otherwise satisfied with the pill and these women
may safely take it. A few women find their diabetic control is adversely
affected by the BCP. For those women, changing the pill may be tried,
but often the BCP must be discontinued.
Women with a family history of
diabetes generally have no trouble taking BCPs. Very rarely, the
BCPs may provoke diabetes (or unmask it). If this happens, alternative
BCPs may be tried but usually the BCPs will be discontinued.
Blood Clot
History
Women who have personally experienced such blood clot problems as
deep-vein thrombophlebitis, pulmonary embolism, cerebrovascular accident
(stroke) or heart attack should not, under ordinary circumstances, take birth
control pills.
Women who have a family history of
such problems but who have not, personally, experienced the problems, may
safely take BCPs.
The Particular Pill She's Using
is not Available
Switch her to a BCP that is available.
This is frequently an issue in
operational settings. Because medical resources are not unlimited in
these situations, it is often necessary to switch to a different pill.
Since most women (90%) will tolerate any BCP without difficulty,
making a switch is usually uneventful and most women will not notice any
difference. It is best to make the switch at the time the old pills
would have been started (after the "off" week), but they can be switched
at any time during the cycle.
It is possible but not common
that they will experience some of the side-effects of nausea, spotting
or breast tenderness during the first month of the switch. After the
first month of the switch, these symptoms generally disappear.
Anticipate that some of these women
will be reluctant to change pills, particularly if they have had good success
with one pill for a long time or if they had difficulty finding a pill that
worked well for them.
Postponing a
Period with BCPs
If a woman is expected to have a menstrual period at a time that is inconvenient
or troublesome from an operational standpoint, it is often possible to postpone
the menstrual flow using BCPs.
Usually, BCPs inhibit ovulation
and menstrual periods occur among women taking BCPs only because the
user stops taking the BCPs for a few days. The fall in hormone levels
triggers an apparently "normal" menstrual flow.
With that principle in mind, a
woman's normal menstrual flow can often be postponed by starting BCPs
within 5 days of the beginning of her last menstrual flow. When she
comes to the end of a 21-day pack of BCPs, she goes immediately into the
next pack of BCPs (skipping the "week off.") She then continues
with the second pack until such time as it becomes convenient to have a
menstrual flow. Stopping the pills at this time will provoke a normal
flow about 3 days after stopping the pills.
This use of pills will usually
keep her from ovulating (and keep her from having a period at the normal
time). It is safe and will not cause any other disruption to the
menstrual flow.
Postponing menstrual periods is
a technique often used by women entering short-term operational settings
when they do not wish to have a menstrual flow while operationally
deployed. There are drawbacks, however, to this approach. While most
women tolerate BCPs without side-effects, some women (~20%) will
experience such side effects as breast tenderness, nausea and spotting.
Most of these side effects will occur during the first month of BCP
usage. So a woman who takes BCPs for 6 weeks to postpone a menstrual
period may be substituting one nuisance (menses at an inopportune time)
for another nuisance (nausea, breast tenderness, spotting). One way to
avoid these problems is to begin the BCPs well enough in advance of the
operational commitment that any minor side effects have worn off.
Another issue to consider is
that while BCPs usually inhibit ovulation, they don't always inhibit
ovulation. In other words, this menstrual-flow-postponing-protocol may
not work, although it usually does.
Choose a monophasic, standard
low-dose BCP, such as LoOvral, Ortho Novum 1+35, LoEstrin 1.5/30 or similar
pill when using it for this purpose. Avoid multiphasic pills and extremely low
dose pills as their inhibition of ovulation is less reliable although they
certainly are effective as far as contraception is concerned.
Side
Effects
Most women (about 80%) experience no side effects while taking BCPs.
The rest experience generally
minor side-effects during the first month of BCPs. These side-effects
might include breast tenderness, nausea, spotting or headaches, and
generally disappear after the first month. If they persist, changing to
a different pill, from a different manufacturer, with different hormonal
content, will usually eliminate the problem.
Occasionally, several pills
will need to be tried before the best (least side effect for that
individual person) is found. Very rarely, no satisfactory BCP can be
found and those women will need to make a judgment whether they would
rather continue the BCPs (with the side effect but with the BCP
benefits) or to use an alternative method of contraception.
Breast
Tenderness
Breast tenderness is relatively common during the first month of BCPs
and uncommon thereafter.
Persistent breast tenderness is
most often associated with fibrocystic breasts. Typically, women with
this condition notice the breast tenderness getting much worse just
before menses and much better after the onset of flow. BCPs are a
reasonably effective treatment for fibrocystic breasts so subsequent
development of significant breast pain should be viewed as unusual.
A careful breast exam should be
done to rule out newly-developed breast disease. A recent onset of
significant breast tenderness should raise your suspicions about a
possible unsuspected pregnancy.
Nausea
Nausea occurring after the 1st month or severe nausea at any time should
make you suspicious of pregnancy, and this is usually ruled out by a
negative pregnancy test or convincing patient history.
Weight
Gain
As individuals age, there is a tendency to gain weight, with or
without BCPs. It is difficult to show any significant additional weight
gain in groups of women taking low-dose BCPs compared to groups of women
(of the same age) not taking BCPs.
That said, there are certainly
individual women who gain weight when they take BCPs and lose the weight
when they stop taking the BCPs. Similarly, there are individual women
who lose weight while taking the BCPs and gain it back when they stop.
Headaches
While headaches can have many different causes, it is uncommon for the
birth control pill to provoke headaches.
Migraine headaches generally improve
or stay the same on BCPs, but occasionally get worse.
Premenstrual or menstrual headaches
generally improve on BCPs, but occasionally get worse. If a woman complains of
headaches only during the "off week" of BCPs, you can frequently resolve her
headaches by modifying the way in which she takes her BCPs. These menstrual
headaches are often provoked by the withdrawal of estrogen and progestin that
accompanies the stopping of the BCPs at the end of each cycle.
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One way to resolve this problem
is to shorten the "off week" from seven days to three days. The three
days off is enough to provoke a menstrual flow, but about the time the
hormone levels are low enough to provoke a headache, the woman restarts
a fresh pack of BCPs.
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Another way to resolve this
problem is to eliminate the "off week" entirely. A woman would go
directly from one pack of pills into the next, skipping the placebo
pills or the "off week." She won't have a menstrual flow and won't get
menstrual headaches. After several months of this, she may experience
some breakthrough bleeding which can be safely ignored if occasional. If
she bleeds every day, then the BCPs can be stopped for 3 days to provoke
a period and then restarted continuously for another few months.
Medically, this is equivalent to taking the BCPs in the normal fashion,
but avoids or minimizes the problem of menstrual headaches.
If headaches persist on the BCPs and
alternative formulations or dosage schedules fail to resolve the problem, the
BCPs will generally be stopped.
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Moodiness or
Depression
Most cases of mood change are unrelated to the BCP use, but mood changes are a
recognized potential side effect.
In these cases, switching to a different
BCP from a different manufacturer, with a different hormone formulation,
will often resolve this problem. If the mood changes persist, it may be
worthwhile to stop the BCPs for a month or two to see if this resolves
the problem.
Women with pre-existing depression, with
or without anti-depression medication, can safely take BCPs, but should
be monitored for signs of worsening of their depression.
It is not healthy to remain moody or
depressed for long periods of time, so this is an issue that clearly
will need resolution one way or another.
Vaginal Dryness
Vaginal dryness or decreased lubrication during sexual activities is an uncommon
but not rare side effect.
This occurs when the BCP suppresses
ovarian function (and natural estrogen production) but does not replace
enough estrogen (from the BCP) to fully stimulate the vaginal and vulvar
tissues. Women with this problem complain of vaginal dryness,
irritation, sometimes painful intercourse and diminished lubrication
during sex.
Stopping the BCP will resolve this
problem, but switching to a different pill from a different manufacturer
may also resolve the problem. Adding additional estrogen (such as
Premarin 0.625 daily) can also be effective, but long-term use may pose
added cardiovascular risks such as is seen in the medium-dose or
high-dose BCPs. "Personal Lubricants" can be used to overcome the
problem, such as Lubrin, Replense, or KY Jelly.
Decreased Libido
(Sex-Drive)
Some women notice diminished interest in sex
while taking BCPs.
Changing to a different BCP from a
different manufacturer may resolve this problem, but some of these women
find that no matter what brand of BCP they take, they experience this
problem.
There are many possible causes of
decreased libido, including stress and relationship problems. To be
certain the cause is the BCPs requires stopping the BCPs for a
reasonable period of time (1-3 months) and seeing if the libido returns.
Then, the BCPs are restarted to see if libido again changes.
Painful Menstrual Cramps
This is an unusual complaint for someone taking the birth control pill.
Usually, BCPs make menstrual cramps
better and many women find they have no cramps at all while taking BCPs.
For someone to notice worsening of menstrual cramps while taking BCPs
suggests that some other medical problem has developed, such as pelvic
infection or endometriosis.
In an operational environment, it is may
be worthwhile to obtain cervical cultures for chlamydia and gonorrhea,
but many physicians would give a course of antibiotics considering the
varying degrees of reliability of such cultures and unusual nature of
the symptoms in such circumstances. Good choices for antibiotics in this
situation would include any of the following:
- Doxycycline 100 mg PO BID x 7 days
- Azithromycin 1 g orally in a single
dose
- Erythromycin base 500 mg orally four
times a day for 7 days
- Erythromycin ethylsuccinate 800 mg
orally four times a day for 7 days
- Ofloxacin 300 mg orally twice a day
for 7 days.
The symptoms of menstrual cramps
(dysmenorrhea) on BCPs can usually be relieved by taking the BCPs
continuously, without stopping for the "off week." Whenever the
operational commitment is complete, gynecologic consultation can be very
useful to look for the many causes of cyclic pelvic pain.
Continuous Birth
Control Pills
In some operational settings, it may be desirable to avoid menstrual
flows completely. Depending on the tactical situation, changing sanitary pads or
tampons can be difficult, distracting or dangerous. Women with significant
menstrual symptoms (cramps, malaise, depression) may find it easier to complete
their mission if menstruation is avoided altogether.
Normally, women take BCPs for 3 weeks and
then stop the BCPs for a week. During the "off week," they have their
menstrual period. The reason they have a menstrual flow at that
particular time is because they stopped taking the BCPs. In other words,
the menstrual flow is really a hormone withdrawal bleed. If they didn't
stop taking their BCPs, they wouldn't have a period.
Using this principle, a woman can go
directly from one pack of pills into the next, skipping the "week off."
She won't have a period. At the end of the second pack of pills, she can
again go directly into the third pack, skipping the "week off' and
skipping a menstrual flow.
This way of taking BCPs is safe and just
as effective in preventing pregnancy as taking them the normal way. The
only drawback is that she loses the regular, monthly feedback of a
menstrual flow, reassuring her that she is not pregnant. In practice,
the BCPs are so powerfully effective that effectiveness is not really an
issue. Should a woman become pregnant despite the use of BCPs (very,
very rare), she will have other symptoms suggesting the pregnancy,
including breast tenderness, fatigue, nausea and bloating.
In theory, women could use continuous
BCPs indefinitely and never have a period so long as she continued
taking the pills. Actually, there are two limiting factors to this
approach. First, most women taking continuous BCPs will eventually
experience some spotting or breakthrough bleeding. If it is mild and
occasional, it is generally ignored. If it is daily or heavy, you can:
- Stop the BCPs for 3 days, provoking a
period (withdrawal flow), and then resume continuous BCPs until the
spotting once again becomes annoying.
- Add a small amount of estrogen
(Premarin 0.625/day, Estrace 1.0/day, etc.) to each BCP. This
additional estrogen will stimulate the uterine lining to become a
little thicker and less fragile.
- Add any non-steroidal
anti-inflammatory agents (NSAID) with significant anti-prostaglandin
activity. This will reduce the force of the normal, physiologic
uterine contractions and reduce or eliminate the spotting.
Second, some women will occasionally
experience a break-through ovulation, followed two weeks later by a
menstrual flow. BCPs normally suppress ovulation, but their
contraceptive effectiveness does not depend totally on ovulation
inhibition. BCPs also change cervical mucous, fallopian tube motility,
endometrial receptivity and doubtlessly has other effects. Particularly
with low-dose BCPs, some women will ovulate anyway, although it is
usually not noticed (when it occurs in phase with the BCP's), and
pregnancy does not occur. For women taking continuous BCPs, any
ovulation will inevitably be followed 2 weeks later by a full menstrual
flow (whether she's taking BCPs or not), and such an event will
certainly be noticed. If the woman taking continuous BCPs has a
full-blown period, then it is wise to change to a different pill from a
different manufacturer. Monophasic pills work better for this purpose
than multiphasic pills.
No Period or Very
Light Period
The heaviness of a menstrual flow depends on the thickness of the
lining of the uterus just before the onset of menses. The thicker the lining,
the heavier the flow. In women using low-dose BCPs (for example: Ortho
Novum, LoOvral, Ovcon, etc.), there is a tendency for the uterine lining to
become very thin, over the course of many months.
Clinically, this is reflected as lighter and
lighter periods which may even stop completely.
This is not a dangerous condition and will
resolve if the BCPs are stopped. Stopping the BCPs is not necessary, however,
because there are other safe alternatives. If the periods are simply very
light (1-2 days), you can ignore the problem because this situation poses no
threat to the patient.
If periods have totally stopped:
- Rule out pregnancy.
- You may change to a different BCP with
different hormone in it. This will often lead to recognizable periods
because the different hormone is metabolized differently.
- You may add estrogen (Premarin .625 mg
or Esterase 1 mg) to each BCP to increase the estrogen stimulation of
the uterine lining, increasing its' thickness and leading to heavier
periods. After the desired effect has been achieved (recognizable
periods), the extra estrogen can be stopped.
- You may safely reassure the patient
and allow her to remain without periods while taking the BCPs. As long
as she otherwise feels well, the absence of periods while taking BCPs
is not known to have any adverse effects and some women prefer to
avoid monthly flows.
Spotting Between
Periods
This symptom is common during the first month of BCPs, particularly
with some of the multiphasic BCPs.
This is not a dangerous condition, but
may be a nuisance to the patient. In the presence of a normal Pap smear,
this symptom can be safely ignored for two months and more likely than
not, it will go away.
If spotting persists, changing to
fixed-dose, mono-phasic BCP (such as Ortho Novum 1/35 or LoOvral) will
usually solve the problem, particularly if you switch to a different
manufacturer.
Occasionally, women spot even following
this change and these women should stop the BCP briefly to make sure
this symptom goes away. So long as the spotting disappears with
discontinuation of the BCP, you can safely conclude that the spotting
was due to the BCP and you may resume the BCP if you like. The spotting
may return, but poses no threat.
Other benign conditions can cause
spotting, such as endocervical or endometrial polyps, cervical
irritation, and uterine fibroid tumors, but none of these pose an
immediate threat and can reasonably be ignored for months if necessary
until definitive gynecologic consultation can be obtained.
Uterine malignancy in a woman under 35 is
extremely rare, particularly if that woman has been on BCPs. Spotting
caused by uterine malignancy won't go away if BCPs are discontinued.
Cervical malignancy can be reasonably excluded by a recent (within 1
year) normal Pap smear and the absence of a visible lesion on the
cervix. Vaginal cancer (extremely rare) is ruled out by a normal vaginal
exam.
Periods at the Wrong
Time
If a full menstrual flow occurs while the woman is taking her pills, this
usually means she has ovulated despite the BCPs.
This doesn't mean she will become pregnant,
since the BCP has a number of ways of preventing pregnancy in addition to
inhibiting ovulation, but it may increase slightly the statistical chance of
pregnancy.
If she continues to take the same BCP according
to her usual routine, the BCP may, over the next month or two, achieve
reasonable control over the menstrual cycle. Backup methods of contraception
should be employed during this time.
Alternatively, many gynecologists will stop the
BCPs for 1-2 months to allow the woman's normal cycle to re-assert itself, and
then resume BCPs (but from a different manufacturer, often using monophasic
rather than multi-phasic BCPs) in step with the woman's own cycle. This means
starting the BCP the 5th day after the beginning of flow, or alternatively,
the first Sunday after the onset of the flow.
Pregnancy may also cause bleeding during the
pill cycle.
Other causes for episodic abnormal
bleeding include uterine fibroid tumors, uterine polyps, trauma and
malignancy. A physical exam will reveal some of these but others will
require more sophisticated gynecologic evaluation. Remember, uterine
malignancy under age 35 is very rare and vaginal malignancy is
extraordinarily rare. Cervical malignancy in the presence of a normal
Pap smear is also very uncommon.
If abnormal bleeding persists,
gynecologic consultation will be necessary, but this can be safely
accomplished within weeks to months so long as the:
- patient is not bleeding heavily and
continuously
- examination is normal
- Pap smear is within 1 year
- patient is less than 35 years old
Antibiotics
When taking Birth Control Pills and antibiotics, it is generally not necessary
to use any form of back-up contraception.
Taking antibiotics may lead to altered
intestinal flora and ultimately to changed levels of hormone in the
patient's blood stream. This observation has led some authorities to
suggest the use of back-up contraception, believing that the changed
levels of hormone might diminish the effectiveness of the BCP.
In controlled studies, this theory has
not been proven, and in the case of tetracycline and chlortetracycline,
no increased risk of pregnancy was found.
If taking antibiotics has any effect at
all on pregnancy rates, the effect must be very small and is not likely
to have much clinical relevance in an operational setting.
Thinks She May be
Pregnant
You should find out.
BCPs are the most effective reversible
method of contraception and failures are uncommon. Factors which
increase the likelihood of failure would include skipping BCPs or taking
an interfering drug. Pregnancies may rarely occur in women taking the
BCP correctly.
Any time any woman taking BCPs thinks she
might be pregnant, get a sensitive pregnancy test. Usually, she'll be
wrong and not pregnant, but occasionally, she'll be right and in such
cases the BCP should be immediately stopped.
Overdose
A single overdose of BCPs is not likely to cause any serious harm. Nausea,
breast tenderness, and possibly a BCP withdrawal bleed (menstrual flow or
spotting) are possibilities if large numbers of BCPs are taken all at once.
Gastric lavage or induced vomiting are unnecessary.
If the overdose was accidental, consideration
of alternative methods of contraception can be explored, particularly those
requiring less individual attention to detail.
If the overdose was intentional, psychiatric
evaluation is important as other, more threatening attempts at self-harm may
follow.
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