The contraceptive Pill

The Pill is an extremely good method of contraception – which is why roughly 100 million women worldwide are taking it.

It's a combination of two hormones – that's why it's often called 'the combined Pill,' or 'the combined oral contraceptive' (or 'COC').

The two hormones are:

• a oestrogen
• a progestogen.
• In fact, there are many oestrogens and progestogens.

All of them are broadly similar to natural female hormones which are produced in your body. Unfortunately, some of them are more likely than others to cause side-effects (such as clotting). It's important that you go on a Pill which has a low risk of causing adverse effects. Don't go on a brand of Pill unless the doctor assures you that it is 'low-risk'.

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At the present moment, incredibly there are over forty brands of Pill in the UK. Many of them are on the market for purely commercial reasons – rather than for the good of your health. Some of them definitely couldn't be described as 'low risk.' So take care.

Treatments for contraception

How does it work?

The Pill works by stopping your body from ovulating (ie releasing an ovum – or 'egg') each month. With most brands of Pill, you take it for three weeks, and then have a week's break. During the week ''off', you should have a period – and these 'Pill periods' tend to be much lighter and shorter, and usually pain-free. That's why for vast numbers of women, the Pill has ensured that 'the curse' is no longer a 'curse'.

Drawbacks of the Pill

The Pill also has its drawbacks – notably a tendency to cause clotting (thrombosis) in a small number of women. One particular group of Pills (called 'third-generation Pills') is linked with a rather higher rate of thrombosis than other types. Regrettably, many women are still on them.

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Is the contraceptive Pill safe?

Although it has now been over 60 years since it was first used (in Puerto Rico in 1956), there are still occasional 'Pill scares' – when newspapers point out the dangers of Pill taking – and in particular the risk of fatal thrombosis. However, the fact that it remains so staggeringly popular (with over three million users in the UK alone) does indicate that for huge numbers of women, the slight risks are outweighed by the benefits.

Fortunately, recent news about Pill safety has mostly been good. For instance, in 2010, the Royal College of General Practitioners produced an important report that revealed Pill-users have a 12 per cent reduction in their risk of developing cancer. The researchers studied 46,000 women over a period of 40 years and found that those who had taken the Pill were less likely to die of cancer, heart disease or stroke. The report also found that breast cancer rates are the same in women who have used the Pill and those who haven't. This finding – if it is confirmed – goes some way towards diminishing previous fears about the Pill and breast carcinoma.

Your initial check-up

When you want to start on the Pill, you should see a doctor (or family planning nurse) and have a short check-up. This is partly to see if you have any risk factors – especially smoking – that would make you more liable to deep vein thrombosis (DVT), heart attacks or strokes. You'll have your blood pressure taken, because of the fact that a raised BP is a risk factor for thrombosis.

Another important factor the doctor will be looking out for is obesity. Being overweight also increases your chances of thrombosis. At your first visit, quite apart from assessing risk factors, the health professional should explain to you exactly how to take the Pill, and can answer any queries you've got. Your doctor should also enquire about any history of clotting among your relatives. You see, some women inherit a family tendency to thrombosis (see below). Incidentally, some people still think that you need to have a vaginal examination before going on the Pill. That hasn't been the case for many years. But if you've reached the 'eligible' age for smear test, it's a good idea to have one.

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How effective is the ordinary Pill?

It's very effective indeed, which is why so many millions of women rely on it.

If you take it exactly as prescribed, its effectiveness is likely to be quite close to 100 per cent.

Put it another way: let's say that 100 women use the Pill for a year and that all of them never forget to take a tablet. It's likely that not a single one of them will get pregnant.

In contrast, if they were all relying on the condom instead, probably about two to five of them would become pregnant. And if they used no contraception at all, perhaps 20 to 40 of them would fall pregnant !

So the Pill is just about the most effective method of contraception there is, apart from sterilisation and vasectomy .

How do you take the Pill?

In Britain, women are mostly advised to start their very first pack of the Pill on the first day of a period. That way, they're protected against pregnancy immediately. Other countries have slightly different starting regimes.

In the UK, you're usually given a pack that contains 21 pills, and you take one every day for three weeks. At the end of those three weeks, you break for a week. During those seven days, you'll have your period .

If you wish, you can take seven 'dummy' tablets during the week's break. Brands that have seven dummy tablets are called every day (ED) ones.

Stopping the Pill at the end of the 21-day pack brings on your period.

After the week's break, you start on your next packet. So it's 'three weeks on and one week off' throughout the year.

If you want to, you can set your mobile phone so that it beeps at the same time every day to remind you to take your Pill.

Note: In the case of several recently-marketed brands of Pill, the makers have decided that their packs will contain 24 or 26 active tablets, instead of the traditional 21. Don't let this confuse you.

What are the good points about the Pill?

The Pill usually makes periods shorter and lighter. Because of this, you are less likely to become anaemic. If you have acne. the Pill should usually improve it – but not always.

The Pill is useful if you want to delay having a period for a special occasion, such as a holiday. By taking two packets back-to-back without a week's break, you can avoid having your period at an inconvenient time.

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In addition, it decreases your chances of getting certain cancers, although it increases the risk of others.

But can't it give you a lot of side-effects when you start?

Yes. During the first few packs of the Pill, many women get minor, passing side-effects, such as:

• headaches
• nausea
• breast tenderness
• slight weight gain
• slight 'spotting' of blood between periods.

These side-effects usually go away after the first few packs. If they don't, it's easy to get rid of them by simply switching to another brand. For a complete list of side-effects, please read the leaflet that comes with your Pills.

What about serious side-effects?

There's no doubt at all that the Pill can occasionally cause serious problems like:

• deep vein thrombosis. This is now known to be more common in women who are taking high oestrogen Pills and also third-generation Pills containing the progestogens desogestrel and gestodene – see below
• heart attacks
• strokes.

Fortunately, these events are rare. But they are much more likely to happen if you have certain 'risk factors', which include:

• being a smoker
• having a family history of thrombosis or some similar illness (say, if your mother had a heart attack or a deep vein thrombosis at 40)
• being severely overweight
• being diabetic (though quite a few non-smoking diabetics do use the Pill, under careful supervision)
• high blood pressure
• high cholesterol level (hypercholesterolaemia)
• past history of phlebitis (vein inflammation) or thrombophlebitis
• being immobile for a while (especially when having a surgical operation).

There are other risk factors, for instance making a very long journey in a plane or a cramped car seat. Your doctor or family planning nurse can give you more details.

The risk is now known to be greater in the first year of taking the Pill. But it also increases a little as you get older, which is why many women come off the Pill some time after the age of 35.

What is the risk of clotting (thrombosis)?

The Pill side-effect that every woman should know about is thrombosis (clotting). This can occur in the veins of the calves (deep vein thrombosis or DVT).

Unfortunately, clots in that area can travel upwards to the lungs and cause a very serious condition called pulmonary embolism or venous thromboembolism (VTE) – which can be fatal.

Any woman can get a thrombosis – particularly as she grows older. But the risk is increased by the Pill, and by pregnancy.

According to the European Medicines Agency, the chances of getting a VTE in the course of a year are:

• In a non-pregnant woman who is not taking the Pill: one in 5,000
• In a woman taking a 'traditional' Pill: roughly one in 1,700
• In a woman taking a 'third-generation' Pill: roughly one in 1,000.

What this comes down to is that if you're on a third generation Pill, you have 60 per cent greater chance of a VTE, compared with someone who is on a traditional Pill.

The risk of clotting is also increased by
taking brands of Pill which contain a lot of oestrogen .

As you can see, the risk to you is not very big. But it is certainly worth considering.

Familial blood factors

Certain blood-clotting abnormalities that run in many families make you more liable to clotting.

The best-known of these is Factor V Leiden. If you have this, we suggest you go for another form of contraception.

Hughes' syndrome

In the last few years, it's become evident that a lot of women have something called Hughes' syndrome (anti-phospholipid syndrome, or APLS).

This blood disorder predisposes them to serious blood clotting. If you have Hughes' syndrome, you should definitely not go on the Pill.

In the early part of this century, new research showed that women who have severe migraine and use the Pill run an unacceptable risk of having a stroke.

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In particular, you should not go on the Pill if you have severe migraine, or if you have migraine with 'aura', which means odd 'warning'
symptoms, like flashing lights or noises or smells.

However, at the European Society of Contraception and Reproductive Health conference in Lisbon in 2014, we learned that British women who suffer from migraine are not getting adequate contraceptive advice about the dangers of the Pill.

In summary, King's College London researchers – Adan and Aslam – found that of 750 women who had been prescribed the combined Pill during the previous 12 months, 36 had a known history of migraine – and 17 of them had migraine with aura. However, only four out of the 36 women had been asked about a personal history of migraine.

So it seems entirely possible that a high percentage of British women with severe migraine may not be aware of the potential risks to their health.

Does age affect whether you should take the Pill?

Yes. The Pill is extraordinarily safe for young women in their teens or 20s who have no risk factors, such as smoking. But when you get to the age of 35 or 40, the chances of having a thrombosis (clot) are starting to increase.

In practice, there are some women in their 40s who still take the Pill. But many others change to the mini-Pill, the diaphragm, or the Mirena IUS, or else choose sterilisation (or encourage their partners to have a vasectomy ).

What about cancer?

The Pill does affect your risk of certain types of cancer – and when you first decide to go on it, you should be told about this.

But it's important for you to realise that the Pill actually reduces your chances of getting some cancers – while it increases the risk of others.

As far as we know, the Pill reduces your chance of getting:

The Pill increases your risk of getting:

• cancer of the cervix
• a very rare form of liver cancer
• possibly breast cancer – but the risk falls after you stop taking the Pill.

Does anything make the Pill less likely to work?

Yes - these factors can reduce the effectiveness
of your Pill:

• forgetting Pills – especially at the beginning or end of a pack
• having diarrhoea and/or vomiting (a common holiday risk)
• taking certain anti-epilepsy drugs, including phenytoin (eg Epanutin ) and carbamazepine (eg Tegretol ). It has been agreed that the Pill should NOT be taken by women who are on the antiepilepsy drug lamotrigine (Lamictal) .
• taking the antibiotics rifampicin (Rifadin. Rimactane ) or rifabutin (Mycobutin) for tuberculosis (TB) or other infections.
• taking certain anti-HIV medicines, including ritonavir (eg Norvir )
• taking the morning-after pill called EllaOne (ulipristal acetate). You'd be wise to use extra precautions for two weeks if you are prescribed this as emergency contraception, for example if you've missed Pills. The emergency contraceptive called Levonelle that you can buy over the counter contains a different ingredient and doesn't make the Pill less effective.
• taking the popular herbal remedy St John's wort while you are on the Pill. It reduces the effectiveness of the oral contraceptive, and you may get spotting of blood.

You used to be advised to use extra precautions, such as a condom, if you were prescribed a course of antibiotics like tetracyclines and Amoxil (amoxicillin).

This was because there was a theory that antibiotics could interfere with the Pill. But there has never been any clear evidence of this.

In 2011, the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists issued new guidance about taking ordinary antibiotics while on the Pill.

They stated that 'additional precautions' (such as condoms) are no longer considered necessary because the latest evidence suggests that ordinary antibiotics do NOT reduce the effectiveness of the oral contraceptive.

It's generally agreed that if a course of antibiotics gives you diarrhoea or makes you sick, you do need to use extra precautions. Follow the instructions for diarrhoea and vomiting in the leaflet that comes with your Pill.

If a doctor wants to prescribe any drug of any kind for you, always tell him or her that you're on the Pill.

What if I miss a Pill?

Try not to! Of course people do inevitably miss Pills; it's only human nature.

If you miss only one Pill. you'll probably be OK. Take it as soon as you remember and then take the next one on time, even if that means you're taking the two of them at the same time. Then carry on with pill taking as usual.

If you want to be super careful, you could avoid sex for the next seven days or take extra precautions.

Missing more than one Pill is quite risky – particularly near the beginning or end of a packet. Take the last pill you missed as soon as possible, even if this means taking two pills at the same time. Leave out the other missed ones. You won't be protected and you'll need to avoid sex for the next seven days or take extra precautions.

If you had unprotected sex in the seven days before you missed the pills you may need to take the emergency contraceptive – see below.

If the pills you missed were near the end of the packet you may need to start the next packet without having your pill free week - you should get advice.

To be frank, the 'missed Pill advice' in the leaflets that come with the pills is pretty complicated. If you're in doubt:

• call a family planning clinic or ask a pharmacist for personal advice
• consider using emergency contraception (the morning-after Pill)
• don't have sex until you're sure you're fully protected.

So which Pill should I choose?

Regrettably, very few women do actually choose their own brand of Pill.

The choosing is mainly done by doctors, or sometimes nurses.

Unfortunately, some doctors who don't know much about contraception do tend to pick Pills more or less at random, because they're
cheaper, or even because a sales rep has just mentioned a particular brand to them.

If you want a more informed choice, go to a doctor or nurse who has training in family planning.

I think you should ask for:

• a low-oestrogen Pill
• a second-generation Pill.

The reason for preferring a second-generation (traditional) Pill is that (as indicated above) the ones that were invented iin the late 1980s ('third-generation Pills') are now known to carry a moderately increased risk of thrombosis.

Future developments

In 2016, we seem to
be moving into an era where women will be able to choose whether to take the
Pilll continuously for several months
at a time. This is called 'tailored Pill-taking,' and the idea is that you
would be able to have far fewer periods each year.

Other people also read:

Choosing a contraceptive. the most popular types of contraception.

Last updated 16.06.2016