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The Low Down on the Low-Dose Oral Contraceptive Pills

Loestrin, Mircette, Yasmin, Yaz, Ortho-Tricyclin, Ortho-Novum, and Alesse—the list goes on and on. Many of us have sampled more pills than flavors at our local ice cream shop (even when the sign says one per customer). And no, it is not all in your head; different pills make you feel differently! Who is the culprit, or the Oz, making your body and maybe even mind feel different on Ortho-Tricyclen vs. Yasmin? Drum roll, please: it’s the progesterone!

While almost all oral contraceptive pills share the same type of synthetic estrogen component (ethinyl estradiol, a.k.a. EE) the progesterone content can vary significantly. Some may make you feel good, even great, while others can make you feel down right crummy. In order to understand the difference in progestins, we want you to picture your family tree. Hone in on four consecutive branches, or generations: from great grandma right down to you. And as with most families, generational changes are huge—think landline to the iPhone, black and white TVs to flat-screen monstrosities, a quarter to ride the subway to a whopping $2.50 per ride.

Similar changes can be seen in the generational changes of synthetic progesterone. The first-generation crew was not so specific in whom they “mated and connected with.” Therefore, they would bind to both progesterone and androgen receptors alike. Their affinity for the androgen receptors resulted in some unwanted side effects: think hair, acne, and bloating. Oh, what a joy! Such side effects made them somewhat unattractive and unpopular.

However, over the next several years, scientists found ways to alter the synthetic progesterone component and reduce the androgenic properties; this translated into way less negative side effects and even some positive ones! Such alterations made pills way more appealing and widespread in their use. Bottom line, if one type of pill (a.k.a. progesterone) doesn’t agree with you, try another. There are many “branches” to climb!

Now, while the progestin component varies, the synthetic estrogen component is pretty much always the same—think of the menu at Applebee’s. It’s just not going to change! However, while the estrogen content is always the same, the dose will differ. And what makes the modern-day pills low dose or, even better, low, low dose is the very low dose of estrogen that each pill contains.

Today, most pills have between 20–35 mcg of EE. This is in contrast to traditional pills (circa 1960), which contained about 50 micrograms of estrogen in each pill. The past 50 years have shown us how low we can go on the estrogen—minimizing clots, strokes, and a slew of negative side effects—while maintaining the efficacy. So although lower dose EE = lower negative side effects, lower dose ≠an increased chance of pregnancy. Currently, we are, taking it back to the limbo reference, as low as you can go without giving up on efficacy.

While intuitively, it seems that the lowest would be the best, this is not the case for everyone. Sometimes the low-low versions cause lots-lots of breakthrough bleeding; this can often be fixed by raising the estrogen dose. So just because low-low seems to be the “in thing” to do, it may not be right for your uterus. A slight bump up in the estrogen dose won’t take you back to the doses seen in the 1960s, but it will give your body just enough estrogen to maintain the lining and maintain your sanity.

You might be wondering what is up with the Tri and even Bi part in the name of some pills (e.g., OrthoTri-Cyclen vs. Ortho-Cyclen). For all of you number fans who can’t wait to travel back in time to middle school math class, tri means three, bi means two, and mono means one. The number part of the name describes the number of phases or changes in hormones that will occur throughout the cycle (a.k.a. the pill pack). Monophasic pills (Loestrin, Ortho-Cyclen, Yaz, Yasmin, Seasonale) contain the same amount of estrogen and progestin in all of the active pills. Biphasic pills (two-phase pills; e.g., Mircette, Ortho-Novum) alter the level of estrogen and progestin twice during the active pack. Last, triphasic pills (three-phase pills; e.g., Ortho Tri-Cyclen, Enpresse) have three different doses of estrogen and progestin in the active pills; the dose changes every seven days during the first three weeks of the pack. These triphasics were the original pills. Scientists were doing their best to mimic the natural cycle. However, research soon showed us that we didn’t need to vary the dose each week. Slow and steady could also win the race! In fact, monophasic pills are equally as effective and in many ways more tolerable. The consistency of the dose translates into less side effects and less breakthrough bleeding.

We have covered doses, phases, and progestins. Last but certainly not least is the number of active pills contained within the pill pack. Traditionally, pill packs contained 21 active pills and seven inactive (a.k.a. placebo or sugar pills). This, like the triphasic pills, was designed to mimic the natural cycle. However, newer formulations have increased the number of active pills to 24 and reduced the number of inactive pills to four. By altering the balance and pushing the pendulum a bit further to the right, there are fewer days off the active pills. Fewer days off the active pills means fewer days of bleeding. In fact, some women skip the placebo pills all together every month and only take the active pills. This does no harm to them or their fertility. It merely removes the need to buy tampons or pads.

Believe it or not, the pill has benefits beyond contraception. It can reduce the risk of ovarian and endometrial cancer, improve acne and unwanted hair growth, regulate the menstrual cycle, decrease heavy menses, reduce the size of fibroids and painful periods, treat PMS symptoms and menstrual migraines, and offer symptomatic relief to women with endometriosis. The list is long, and the benefits variable. Simply stated, the pill can do a lot more than prevent pregnancy!

However, with every peak there is always a valley, and with every pro, there is also a con. Even with the best medications, you must read the fine print. Although the pill has a lot of benefits, there are some of us for whom the glass slipper just doesn’t fit. Certain medical problems preclude women from even trying to shove their foot in! Such conditions include women with a history of blood clots (or a family member who harbors an inherited clotting disorder), impaired liver function, smokers older than 35 years, elevated blood pressure, migraines with visual aura (think flashing lights), and markedly elevated cholesterol/triglycerides. Before starting you on the pill your doctor will likely take a thorough medical and family history to make sure you are a good candidate.

You will likely not marry the first person you date or say yes to the first dress you try on. Don’t quit after one bad month on OCPs; just because one didn’t agree with you it doesn’t mean the dozen others will too. OCPs are a great form of birth control and come with a lot of other benefits. As long as you can remember to take it daily (put it by your toothbrush or face wash!), it’s worth giving it a go. You’ll find something that fits!

Oops, I Missed a Pill…Did I Mess Everything Up?

One of the most frequently Googled GYN questions is “What do I do when I miss my pill?” Pill oversights, although common, can cause a lot of panic and fear. Getting pregnant now is not an option! Staring at the pack and realizing you are up to Tuesday but it is Thursday can be horrifying. However, the reality is that, if you haven’t at some point in your pill-taking career missed a pill, you deserve a medal. Almost all of us have had an oops or an uh-oh over our one, five, ten, or fifteen years of taking the pill. You are most certainly not alone.

When you miss a pill, the first question to ask yourself is, how many did I miss? When you miss just one pill, it’s no big deal. Just take the missing pill as soon as soon as the light goes off in your head. If it is not until the next day, take the missed pill plus that day’s pill together.

If you miss two-plus pills, that is slightly more of an issue and requires some more effort. Again, once you have your “a-ha I missed my pills moment,” take both ASAP. Then resume your daily pill schedule.

However, forgetting to take a pill is like forgetting to brake when approaching a red light. The ignition will rev up, and you may roll right through an intersection. Without the daily suppressive effect of the pill, your brain may start to develop a follicle and get ready to release an egg. So to prevent pregnancy, the best thing to do is use an additional form of contraception (a.k.a. condoms) until you have taken seven days of active pills.

If the oops was in the last week of the active pills, don’t take the placebo week; restart a new pack a week early.

If the error was in the first week and you had unprotected sex, you should strongly consider emergency contraception (a.k.a. Plan B) as well as continue with your current pack for maximal protection. Call your doctor, and let him or her know what happened so that together you can design a plan that will prevent pregnancy.

When thinking about pill errors, think in terms of sevens:

  • It takes about seven days of continuous pill use to prevent ovulation.
  • Never take fewer than 21 consecutive active pills.
  • Never have more than seven pill-free days (any longer than this gives the body a chance to ovulate).

While seven may not be your lucky number, if you follow those rules you will make sure you stay lucky (and not pregnant)! One notable news flash: if you forgot to take the sugar pill (a.k.a. the placebo one), don’t sweat it. Those pills are not doing anything more than keeping you in the habit of taking a daily pill. However, if you miss any of the active pills, even if you followed the back-up schedule, take a pregnancy test. Although many women on the low dose or the low, low dose pills don’t get a period, it’s best to check and confirm a negative.

The majority of unintended pregnancies on the pill occur from missed pills. If you are one of those who seem to suffer from forgetfulness as it relates to the pill, then oral contraceptives are probably not right for you. There are several other forms of reliable hormonal and non-hormonal contraception that can do the same trick without requiring the daily light bulb to go off.

Remember, mistakes happen. Most of these momentary lapses are not a big deal. In an effort to minimize these hiccups, pair your pill pack with a daily activity that you never forget—brushing your teeth, washing your face, taking your contacts out. This will help minimize mistakes and maximize effectiveness. We want this to work for you until you are ready to work on becoming a mom!