Thanks to the plethora of options at your disposal, choosing the right birth control can feel like you’re blindfolded and trying to pin the tail on the contraceptive donkey. Even if you narrow your focus to just the pill, you still have a lot of possible choices out there. But if you do your homework—and are prepared to possibly engage in some trial and error—you can pinpoint the best birth control pill based on your needs.
First things first, there are two main kinds of birth control pills: ones with estrogen and ones without.
Birth control pills that contain a mixture of estrogen and progestin (combination pills) are the most common type out there.
So, how do combination pills work to keep you pregnancy-free? During your typical menstrual cycle, there’s a hormonal surge that triggers the release of an egg to potentially be fertilized, Justine P. Wu, M.D., a family planning expert and assistant professor in the department of family medicine within the department of obstetrics and gynecology at the University of Michigan, tells SELF.
“[Estrogen] overrides that normal hormonal surge, and because of that, there’s no egg released,” says Dr. Wu, who is also a board chair member of the Association of Reproductive Health Professionals. Progestin does its part by thickening your cervical mucus to make it harder for sperm to move and thinning your uterine lining, which makes it less likely for any egg that does get fertilized to attach to it.
Different brands of combination pills can differ in many ways, including how much estrogen and progestin they contain within each 28-pill pack and how often (if at all) those levels fluctuate throughout the month. There’s also the fact that many, but not all, combination pills have placebos at the end of the month to allow for a withdrawal bleed that simulates your period. We’ll dive into why these distinctions might matter in more detail later, but for right now, just keep in mind that combination pills contain estrogen and progestin and all work in the same way across the board.
Then there are birth control pills without estrogen, which are known as progestin-only pills (also called the minipill). These come in packs of 28 active pills (no placebos) and deliver a steady dose of progestin to thicken your cervical mucus and thin your uterine lining. If you still have enough uterine lining to shed, you may experience a withdrawal bleed (your period) at some point during the month. (It won’t necessarily come in the last week of the pack the way it would with combination pills, since you take these pills every day.)
Research shows that birth control pills are over 99 percent effective at preventing pregnancy—if you use them perfectly.
With perfect use (which means taking them consistently and correctly every single time), research estimates that the birth control pill has a failure rate of 0.3 percent. This indicates that fewer than one woman out of every 100 will get pregnant in the first year of taking birth control pills perfectly. When you incorporate human error (which researchers refer to as “typical use”), the failure rate for birth control pills is thought to be about 9 percent, according to the Centers for Disease Control and Prevention, meaning nine out of every 100 women getting pregnant in the first year of taking the pill this way.
So, what constitutes typical use versus perfect use? Typical use could include taking a pill late or forgetting it completely. This depends somewhat on the type of pill you’re taking and how late you were on that missed dose. If you’re on a combined birth control pill, the instructions for what to do after a missed dose may vary from pill to pill, so check the prescribing information that came with your pill pack for details. With progestin-only pills, perfect use requires you to take the pill within the same three-hour window to be the most effective, according to the American College of Obstetricians and Gynecologists (ACOG).
For context on where the pill falls on the pregnancy-protection spectrum, it’s more effective than internal condoms (which carry a 2 and 18 percent failure rate with perfect and typical use, respectively), provides equivalent protection to the vaginal ring and patch when used typically and perfectly, and isn’t quite as excellent as the hormonal IUD or implant (which both have a failure rate of less than 1 percent, even with typical use).
The right birth control pill for you will depend on some personal factors, so let’s go over some pros and cons of each type.
Pills with estrogen (combination pills)
- They’re a little harder to mess up than progestin-only pills. Because combination pills use two hormones to prevent pregnancy (and at higher levels than in estrogen-free birth control pills), they’re thought to be slightly more effective than the minipill, according to the Mayo Clinic. Because of this, you don’t have to take combined birth control pills at the exact same time every day for them to be effective, whereas you really need to be mindful of this when you’re taking progestin-only pills. Researchers aren’t sure of the exact disparity between efficacy rates here, but it’s still worth noting if you’re someone who can’t always take a pill within the same three-hour window.
- They can help with PMS. Combination birth control pills’ steadying of your normal estrogen fluctuations means you may experience fewer PMS symptoms like bloating and mood swings, according to the Mayo Clinic.
- You may experience lighter periods and less painful cramps. This is thanks to combination pills’ progestin, which keeps your uterine lining thinner so there’s less to shed during your period. Your period could even stop altogether. With less uterine lining, you may also produce fewer prostaglandins, which are hormone-like chemicals that make your uterus cramp, leading to period pain. These benefits can be especially useful for people who have conditions that make their periods hellishly painful, like endometriosis.
- They can help clear up your skin if you have acne. By suppressing your ovulation, combination pills tamp down on the testosterone spikes that often accompany ovulation, Dr. Wu explains. Excessive testosterone production is linked with acne, so curbing your levels can lead to clearer skin.
- They temporarily prevent you from ovulating, which could be a bonus for some people. Since the estrogen in combination pills suppresses ovulation, they can help if you’re prone to developing uncomfortable ovarian cysts. Ovarian cysts can happen for two ovulation-related reasons: because an ovarian follicle that houses an egg keeps growing when it should instead break open to release said egg, or because the follicle collects fluid after ovulation and continues to grow when it shouldn’t, the Mayo Clinic explains. Sometimes the resulting cyst is completely harmless, but other times it can cause severe pain, particularly if it ruptures or twists your ovary around itself.
The ovulation suppression aspect here can also be helpful if you’re prone to a kind of bizarre, painful phenomenon known as mittelschmerz. It’s basically an abdominal aching or cramping sensation that can happen when a follicle containing an egg stretches your ovary as it grows in preparation for ovulation. It can also happen right as the follicle bursts to release the egg.
- You may be able to manipulate your period with certain formulations of combined birth control pills. It’s theoretically possible to make your period come earlier by moving up when you take the placebo week of combination pills. Or you can skip your period entirely by skipping the placebo week and immediately starting a new pack of active pills.
Using the pill this way means you’re not using it for its prescribed intent, so you should always talk with your doctor to make sure they’re on board with this before you try it. It can also make you more liable to experience breakthrough bleeding.
- They may help reduce menstrual migraines if used continuously under a doctor’s supervision. During your menstrual cycle, your levels of estrogen fluctuate. This can trigger menstruation-related migraines in some people, the Mayo Clinic says. “By using the pill continuously and not having the withdrawal bleed, you can suppress those horrible headaches,” Dr. Wu explains.
- They may reduce your risk of certain cancers. Combination pills come with a reduced risk of endometrial, ovarian, and colorectal cancers. Researchers are still working to understand the nuances of these connections, but it seems as though combination pills suppress rapid growth in endometrial cells, reduce your exposure to naturally occurring hormones tied with ovulation, and lower the amount of bile acids in your blood, according to the National Cancer Institute. These mechanisms are tied with lower risks of endometrial, ovarian, and colorectal cancers, respectively.
To be clear, that’s not to say taking a combination pill means you have zero risk of getting these cancers, but that enough research has been done to show that the pill is associated with lowered incidences of these specific kinds of cancer.
- Your fertility should return pretty much immediately after you quit combination birth control pills, if that’s of interest to you.
- The estrogen in combination pills can cause some side effects. This can include things like achy breasts, the Mayo Clinic explains. Lowered libido is another possible complaint, since ovulation suppression cuts down on natural testosterone increases that might make you feel like having sex.
It’s possible that these kinds of side effects will decrease with time, so talk to your doctor about how likely it is that yours may stick around. You might just need a different formulation of the pill that has different amounts of estrogen. “Sometimes there’s a lot of troubleshooting,” Raegan McDonald-Mosley, M.D., chief medical officer at Planned Parenthood Federation of America, tells SELF.
- They don’t provide any protection against STIs or HIV. For the record, this goes for all birth control methods except for internal and external condoms. So, if you’re at risk of getting STIs (like if you’re having sex with more than one partner or don’t know your partner’s STI status), you’ll need to rely on something like a condom or dental dam to better protect yourself during sex, whether or not you’re on the pill.
- You have to remember to take the pill every single day. If you’re aiming for perfect use (which you really should be, since that’s when you’re most protected against pregnancy), you’ll need to remember to take the pill every day. You can’t “set it and forget it” with the pill as you can with, say, an IUD.
- They’re not recommended for people who are breastfeeding. If you’re breastfeeding, estrogen may affect your milk supply, according to ACOG, which is why combination pills aren’t advised until at least the fifth week post-delivery.
- They may actually cause or worsen migraines in some people. Kind of confusing, given that they may make migraines better for some lucky folks. For others, though, taking combination birth control pills is what actually brings about this aggressive head pain, the Mayo Clinic says.
Also, there’s some evidence that taking hormonal contraception (especially those with higher amounts of estrogen) if you have migraines with aura (sensory changes that are typically visual, like seeing flashing lights or zigzags) may increase your risk of stroke. This is a really thorny area that isn’t set in stone, because this contraindication may be based on outdated advice. Here’s more information on that. Bottom line: If you have migraines (especially with aura), you need to be clear about that when discussing contraceptive options with your doctor.
- They may increase your risk cardiovascular issues like blood clots and stroke, particularly if you have certain risk factors. This is a complex potential drawback, because it sounds terrifying, but there’s a lot going on beneath the surface. First thing to know: The hormones in birth control pills increase the clotting factors in your blood. (This is mainly due to estrogen, but researchers are still investigating if progestin can also have this effect when combined with certain kinds of estrogen.) If your blood clots up in a vein deep inside your legs, it’s called a deep vein thrombosis. This kind of clot can dissolve on its own, but it can also be life-threatening if it breaks off, travels to your lungs, and blocks your airflow. Blood clots can also lead to stroke.
However, Dr. Wu points out: “The risk [of a blood clot] in a woman who is otherwise healthy is incredibly low.” A 2015 study in BMJ that looked at over 50,000 women put the odds of getting a blood clot while not using hormonal birth control at about 0.04 percent, raising it to between 0.06 and 0.18 percent when on the pill, with variations depending on the specific kind of pill in question. That’s why this is mainly only a concern if you have additional blood clot risk factors like being over 35 and smoking. “It’s also something that has to be put into perspective—the risk of a blood clot is higher when you’re pregnant [than when you’re on the pill],” says Dr. Wu. “Preventing pregnancy in and of itself is lower risk.”
- You may not be a good candidate for combination pills if you have hypertension. This is especially the case if it’s poorly controlled, because the estrogen in them can further raise your blood pressure.
- They may increase your risk of certain cancers. Some evidence shows that the chances of developing breast and cervical cancers are increased in those who take combination pills. Similarly to the lowered risks of getting specific cancers on the pill, this isn’t to say that if you take the pill, you’re absolutely going to wind up with certain cancers—just that the scientific evidence shows the odds of developing breast and cervical cancer are higher in people who take the pill.
This may be because the estrogen and progestin in the pill prompt the growth of some cancers, like those of the breast that respond to those hormones, according to the National Cancer Institute. When it comes to cervical cancer, the issue may be that birth control pills increase how vulnerable cervical cells are to infection with the strains of human papillomavirus that lead to cervical cancer. However, after you stop the pill, any related increased risk of both of these cancers is thought to decline over time.
- They aren’t recommended for people who have or have had breast cancer. This is because the hormones in them have the capacity to stoke the growth of cancers that are receptive to hormones.
If you’ve decided on combination birth control pills, you’re still only about halfway there, because there are various formulations on the market.
There are actually a ton of different birth control pills out there with estrogen and progestin. To help you narrow down your options, here are some questions you should consider:
Do you want a monophasic, biphasic, triphasic, or quadriphasic pill?
While these sound more like phases of the moon, they’re really describing the different ways combination pills deliver their hormonal dosages.
Monophasic pills offer the same amount of estrogen and progestin in every active pill. Biphasic pills contain two different, color-coded hormonal dosages throughout the month’s active pills. As you’ve probably already guessed, triphasic birth control pills contain three different amounts of active hormones in the pill pack. Quadriphasic pills deliver four different hormonal dosages.
As a general rule, multiphasic pills are designed in part to mimic the rise and fall of estrogen and progesterone levels during a regular menstrual cycle, thereby potentially reducing birth control side effects. But various research attempts, such as a 2011 review in Cochrane, haven’t found solid evidence of significant advantages to using multiphasic pills. Many experts recommend that people at the very least start their birth control pill journey with monophasic ones, since they’re simplest.
Do you want a very low hormone version?
Low-dose pills generally have 35 or fewer micrograms of estrogen per active tablet, although the lowest available option contains 10 micrograms of the stuff. Even the highest dose pills today aren’t as chock full of estrogen as they once were.
“A lot of women are asking for ‘the low-dose pill,’ and in reality, they’re all low-dose because they’ve dropped the dose of estrogen significantly from what used it to be,” Dr. Wu points out. The first birth control pill, Enovid, hit the market in 1960 and contained 150 micrograms of estrogen. As such, it was associated much more closely with serious complications like cardiovascular issues.
Even with the reduced doses of estrogen, low-dose pills provide the same pregnancy protection as other combination formulas. But that lower dose can change the side effects you experience. You may not have as much breast tenderness, for instance. And it may help with menstrual migraines by delivering a less dramatic drop in hormones during your placebo week. One major drawback, though, is that the lower levels of estrogen can make you more likely to have breakthrough bleeding.
Do you want a conventional or extended cycle pill?
Conventional pill packs typically come with 21 active and seven inactive pills, allowing for a withdrawal bleed at the end of the month. (Even though it’s totally safe to skip your period, you might like that bloody reassurance that you’re not pregnant.)
Extended cycle pills typically come in packs of 84 active pills—taken back-to-back—and 7 inactive pills, the Mayo Clinic explains. These mega pill packs let you theoretically only have a period four times a year—possibly a major win for anyone who suffers from painful period-related conditions, like endometriosis and menstrual migraines, or for those who just doesn’t want to deal with having their period every month. But, much like low-dose pills, this kind of birth control can make you more liable to breakthrough bleeding.
Do you want a pill formulated to combat PMS/PMDD?
If you experience physical and emotional symptoms like bloating, breast tenderness, and mood swings that are hallmarks of premenstrual syndrome (PMS), combination pills may help ease that time of the month. Same goes if you have premenstrual dysphoric disorder (PMDD), which is characterized by extreme moodiness, depression, anxiety, and other severe symptoms. Taking the active birth control pills back-to-back to skip your period (if approved by your doctor) gives you a steady supply of hormones that can reduce PMS and PMDD symptoms, according to the Mayo Clinic.
But there are also oral contraceptives that contain a synthetic version of progesterone called drospirenone that are FDA-approved for the treatment of PMDD (such as Beyaz and Yaz. It seems as though the drospirenone may reduce how susceptible you are to hormone fluctuations that lead to PMDD symptoms, and it also acts as a diuretic, which helps with bloating.
Not sure if combination pills are right for you? Here’s what you need to know about progestin-only pills (aka, the minipill):
- You may experience lighter periods and less painful cramps. Just like with combination pills, the progestin in the minipill keeps your uterine lining thinner so there’s less to shed during your period. Your period could even stop altogether. With less uterine lining, you may also produce fewer prostaglandins, which are hormone-like chemicals that make your uterus cramp, leading to period pain. These benefits can be especially useful for people who have conditions that make their periods hellishly painful, like endometriosis.
- You can take them while you’re breastfeeding. Unlike estrogen, progestin doesn’t seem to have the potential of messing with your milk supply if you’re breastfeeding, according to ACOG.
- You can take them if you have hypertension. As opposed to estrogen, progestin shouldn’t raise your blood pressure, so the minipill can be a good option if you have hypertension.
- Your fertility should return pretty much immediately after you quit progestin-only pills, if that’s of interest to you.
- You can take them even if you can’t (or don’t want) to take estrogen. If for whatever reason the estrogen in combination birth control pills wasn’t a good fit for you, the progestin-only pill may be a better choice.
- You need to take them within the same three-hour window every single day. With only progestin to lean on (and with lower levels of it than you’ll find in combination pills), you need to be incredibly consistent about taking the minipill around the same time every day, specifically within the same three-hour window. “It’s less forgiving than combined pills, so adherence is really important,” Dr. Wu says.
- You may experience irregular bleeding or spotting. Due to the low level of hormones, you might experience irregular bleeding on the minipill, Dr. Wu says. This is especially true if you don’t take it precisely as you should, within that three-hour timeframe every day.
- You can’t mess around with the minipill to influence your period. Screwing with when you take it in any way can boost your chances of unintended pregnancy, since adhering to the dosage schedule is so important.
- They don’t provide any protection against STIs or HIV. As we mentioned, this goes for all birth control methods except for internal and external condoms. So, if you’re at risk of getting STIs (like if you’re having sex with more than one partner or don’t know your partner’s STI status), you’ll need to rely on something like a condom or dental dam to better protect yourself during sex, whether or not you’re on the pill.
- Since ovulation suppression isn’t guaranteed with progestin-only pills, you might still release eggs sometimes. If you’re susceptible to mittelschmerz (that ovulation pain) or ovarian cysts, the minipill won’t help the way a combined pill would.
- You won’t necessarily reap any of combination pills’ benefits that are related to estrogen. Such as clearer skin or reduced risk of certain cancers.
- Like combination pills, the minipill isn’t a good idea for people who have or have had breast cancer. This is because the progestin in them may help hormone-receptive cancers develop.
- If you do get pregnant while taking the minipill, you have a slightly higher risk of experiencing an ectopic pregnancy. An ectopic pregnancy is a nonviable pregnancy that occurs when the fertilized egg implants somewhere other than the uterus, usually in a fallopian tube, according to the Mayo Clinic. This risk is higher than with combination pills for a few possible reasons.
It seems as though progestin may reduce the activity of cilia (small hair-like structures) in your fallopian tubes. If you do get pregnant, these cilia are supposed to transport the fertilized egg from your fallopian tube to the uterus, but if that doesn’t happen, it can try to implant in the tube instead. If progestin-only pills reliably suppressed ovulation the way combination pills did, this lowered cilia activity probably wouldn’t matter as much. But since they don’t—and since you don’t have much room for error when taking them—you’re more likely to get pregnant with the minipill, then have the fertilized egg latch on in the wrong place.
Still not sure which pill is right for you? Here’s a checklist of important questions you should discuss with your doctor, which might help you narrow down your options.
Based on the information above, you might already have an idea of which kind of pill you’re interested in trying. If not, go into your doctor’s appointment prepared with questions that can help you suss it out. Here’s some inspiration:
- I have [insert any period problems that try to ruin your life here]. Which pill tends to work best for that?
- I’m interested in getting my period less often and/or controlling when it comes. What kind of pill do you recommend?
- Is there anything in my health history that indicates the pill (especially one with estrogen) may not be right for me?
- I’m worried about blood clots and/or stroke. Can we discuss if I have any risk factors that might be red flags?
- Is there any point in me taking multiphasic pills, or should I stick with monophasic ones?
- I really want to avoid [breakthrough bleeding/sore boobs/some other common birth control pill side effect here]. Which pill is least likely to cause this?
- Is there a certain kind of pill that may help my migraines? Or might the pill just make them worse?
- I have a family history of [insert a specific kind of cancer here]. What does that mean for my birth control options?
- Is there any reason low-dose pills might be better or worse for me?
If you’re realizing the pill isn’t right for you, no worries—there are plenty of other contraceptive options from which you can choose.
They range from IUDs that can hang out in your uterus for years to vaginal rings you swap out every three weeks and so much more. Talk with your ob/gyn to explore what’s available to you based on your health history and needs.
“Make sure you’re aware of your options and are not limited by what your friends are taking, because you saw an ad, or the fact that you’ve only been issued a particular pill by your doctor,” Dr. Wu says. After all, it’s called birth control because the end goal is to command your reproductive future with as much confidence as possible, whatever that looks like for you.