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Hormonal Contraception
 
 

Since the FDA approved the first birth control pill in 1960, millions of American women have used hormonal contraception.  Today, nearly a quarter of American women of reproductive age use hormonal contraception, and 86% of women have used it at one time or another during their lives.1 Over time, the hormone dosages have decreased and new ways of using hormones—through patches, implants, vaginal rings, creams, and with extended cycles or continuous use instead of monthly cycle— have been developed, which have improved the safety and user acceptability of hormonal methods.2  However, misperceptions about the risks and benefits of hormonal contraception are pervasive, leaving many women unsure about whether to use hormonal methods and what to expect once beginning a method.

Frequently Asked Questions about Hormonal Contraception

What is hormonal contraception?

How does hormonal contraception work?

How effective is hormonal contraception?

How can a woman obtain hormonal contraception?

What are the side effects of hormonal contraception?

How should a woman take hormonal contraception?

Can a woman choose to use hormonal contraception continuously – without a hormone-free break?

Is hormonal contraception the same thing as the morning-after pill?


Are there women who should not use hormonal contraception?

Are there other benefits to using hormonal contraception besides prevention of pregnancy?

How long after taking hormonal contraception can a woman become pregnant?

Does use of hormonal contraception have an impact on a woman’s risk of acquiring a sexually transmitted infection?

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What is hormonal contraception?

Hormonal contraception is a type of birth control that comes in a variety of forms.  There are currently more than 40 brands of oral contraceptive pills on the market in the United States.  Combined oral contraceptives (OCs), patches and rings contain an estrogen (usually ethinyl estradiol) and a progestin. Hormonal contraception also includes methods that contain only progestin: progestin-only pills (mini-pills), injectables such as Depo Provera, the implant Implanon, and the progestin-releasing intrauterine system called Mirena.   The amount of hormones in each method varies: from the mini-pills with no estrogen to low-estrogen pills with 20 micrograms of estrogen per pill, up to pills with 50 micrograms of estrogen per pill and Depo Provera which is a 150 milligram injection of progestin providing a high dose initially that decreases over time.  Mirena releases 20 micrograms of progestin per day.

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How does hormonal contraception work?

The hormones in some hormonal contraceptives (combined estrogen and progestin) cause the woman’s ovary to stop its monthly hormone cyclic and egg development.  Progestin-only contraceptives also stop the ovary’s monthly cycles in some cases, and in others are effective because of progestin action to thicken cervical mucus and impede sperm transport.

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How effective is hormonal contraception?

Hormonal contraceptives are highly effective at preventing pregnancy.3 When used correctly and consistently, OCs, patches, rings, implants and injectables have a failure rate of less than 1%. However, with “typical use” (the term experts use to account for common human errors: a missed pill, a pill not taken at the same time everyday, etc), failure rates range from 3% to 8%.4

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How can a woman obtain hormonal contraception?

In the United States, women must obtain a prescription for hormonal contraception from a healthcare provider.5  Historically, many providers have required women to have pelvic and breast exams before beginning hormonal contraception.  While pelvic exams can provide information about the health of a woman’s genital tract and reproductive organs, this information is not needed to assess whether a woman can use hormonal contraception, so many health care providers no longer require them.6 Although all women are encouraged to get regular exams regardless of whether they use hormonal contraception, many physicians and women’s health advocates believe that blood pressure measurement and a thorough review of a woman’s medical history are the only necessary prerequisites to initiating hormonal contraception. 7 8 9

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What are the side effects of hormonal contraception?

Each woman responds to hormonal contraception differently.  For most women, side effects are not bothersome enough to be a major consideration.  Most women notice that their menstrual periods are shorter and lighter, with less cramping. Most women also find that acne problems are reduced. The most common side effects reported by women include nausea, breakthrough bleeding, headaches, breast tenderness, weight gain, decreased libido, and depression.  Many women will stop having their period – a side effect that is a benefit for some women and a disadvantage for others. 

While the majority of women who experience side effects find them manageable and continue to take hormonal contraception, an important sub-group of women discontinue hormonal contraceptive within the first year of use.  Between 25% and 60% of these women cite irregular bleeding and medical problems, such as headache and weight gain, as reasons for discontinuation.   All women taking hormonal contraception should monitor their own physical and mental health and discuss any changes they are concerned about with their health care provider.

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How should a woman take hormonal contraception?

Not all methods of hormonal contraception are taken in the same way.  The conventional oral contraceptive packaging instructs women to take three weeks of active hormone pills, followed by seven days of placebo pills.  The labeling on one oral contraceptive product, Seasonale, instructs women to take active hormone pills for three months straight, followed by seven days of placebo pills. The Ortho Evra contraceptive patch is applied to a woman’s body once a week for three weeks, whereas the NuvaRing contraceptive ring is inserted and remains in the vagina for three weeks – both followed by one hormone-free week.  The injectable contraceptive, Depo Provera, is provided once every three months, the implant Implanon lasts for three years, and the hormonal intrauterine system, Mirena, can stay in place for up to five years.

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Can a woman choose to use hormonal contraception continuously – without a hormone-free break?

For several of the shorter term hormonal methods, providers recommend some women practice "extended use” of hormonal contraception, which means a woman would skip the “week off” (placebo pills or the patch/ring-free week) and take hormones continuously, thereby avoiding withdrawal bleeding.  Extended use is also often recommended for women who experience prolonged or excessive bleeding, menstrual migraines, or professional or personal activities that would be disrupted by menstruation.  Some women will opt for extended use only occasionally for convenience purposes, such as for a vacation or athletic event. 

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Is hormonal contraception the same thing as the morning-after pill?

Yes, in certain forms. It is possible to use some brands of oral contraceptives as emergency contraception (EC).10  Although the package labeling does not include this information, the FDA has approved eighteen brands of oral contraceptives as safe for use as EC.  In the event a woman misses a pill, experiences a broken condom during intercourse, or has sex when she did not plan to or want to, she can take Plan B, a progestin-only pill product sold specifically for EC, or she can use a double or triple dose of combined estrogen and progestin oral contraceptive pills to prevent pregnancy.  Not all brands can be used as EC, and, since brands of oral contraceptive pills differ, the number of pills she will take for EC will vary.  The EC Website www.not-2-late.com, hosted by Princeton University, has a complete list of the brands of oral contraceptives that can be used as EC.

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Are there women who should not use hormonal contraception?

Hormonal contraception is safe for use by most women of reproductive age. However, some women have medical conditions or personal characteristics that increase their risk of developing serious complications. For example, advancing age, obesity, hypertension, migraine headaches, diabetes and smoking can increase the risk of stroke, heart attack or blood clots. 11 12 In addition, risks associated with birth control use can vary by method. The risk is higher with methods that combine both progestin and estrogen, particularly the estrogen, drospirenone. Women who use Depo Provera for at least two years may experience a loss of bone density which is a risk factor for osteoporosis and, possibly, fractures. The evidence shows that when women stop using the method, the bone loss is at least partially reversed, but this may be a concern for women with other risk factors for osteoporosis. It is recommended that women who have, or have had, breast cancer should not use hormonal contraception. Women should talk to their health care provider about which method is best for them and whether the risks of serious complications outweigh the benefits of using hormonal contraception.

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Are there other benefits to using hormonal contraception besides prevention of pregnancy?

In addition to its effectiveness at preventing pregnancy, hormonal contraception also offers non-contraceptive health benefits to users. These include reduced risks of ovarian and endometrial cancers, as well as decreased risk of benign breast disease, pelvic inflammatory disease, ovarian cysts and ectopic pregnancy. Hormonal contraception may reduce a woman’s risk of anemia and other symptoms associated with heavy menstrual bleeding.13 Combined products also reduce the severity of acne and hirsutism (excessive body and facial hair) and temporarily improve bone mineral density.14  However, hormonal contraceptives do not protect against sexually transmitted infections, including HIV.

For more information, read a new report from Guttmacher Institute about the additional benefits of hormonal contraceptive pills.

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How long after taking hormonal contraception can a woman become pregnant?

The use of hormonal contraceptives does not have an irreversible affect on fertility.15  The average time for return of fertility among women using OCs and other combined hormonal methods is one to two months after discontinuing use, while women using Depo-Provera generally fertility as women who did not use Depo-Provera after about 10 months from the last injection.16 17

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Does use of hormonal contraception have an impact on a woman’s risk of acquiring a sexually transmitted infection?

Current research indicates that women using certain forms of hormonal contraception appear to be at greater risk for sexually transmitted infections than women who are not using hormonal contraception.  For example, women who use combined OCs appear to be at increased risk for aquiring chlamydia, when compared to women not using contraception.18  In addition, recent studies suggest that women who use Depo Provera have a greater risk for acquiring gonorrhea or chlamydia than women using non-hormonal methods.19  Researchers do not fully understand why women using Depo Provera are at greater risk, and it is not clear whether it is caused by the hormonal contraception or might be explained by other factors, such as number of sex partners. Women who know they are at risk for sexually transmitted infections, have multiple sex partners and cannot negotiate consistent and correct condom use should consider a different method. 

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1 Mosher W, Martinez  G, Chandra A, Abma J, Wilson, S.  Use of Contraception and Use of Family Planning Services in the United States: 1982-2002. National Center for Health Statistics. Advance Data from Vital Health Statistics; 350.

2 Hatcher RA, Trussell J, Stewart F, et al., editors Contraceptive technology eighteenth revised edition. New York: Ardent Media, 2004.

3 Trussell, J. Contraceptive failure in the United States. Contraception 2004;70(2):89-96.

4 Trussell, J. Contraceptive failure in the United States. Contraception 2004;70(2):89-96.

5 In six states, women can obtain emergency contraceptive pills directly from a pharmacist. One pilot project in Washington State is exploring the feasibility of providing other methods of hormonal contraception through pharmacists.

6 Nelson AL. Whose pill is it, anyway? Family Planning Perspectives 2000;32(2):89-90.

7 Hannaford PC and Webb AMC. Evidence-guided prescribing of combined oral contraceptives: consensus statement. Contraception 1996;54:125-9.

8 Scott A and Glasier AF. Are routine breast and pelvic examinations necessary for women starting combined oral contraception? Human Reproduction Update 2004;10(5):449-52.

9 Stewart FH, Harper CC, Ellertson CE, Grimes DA, Sawaya GF, Trussell J. Clinical breast and pelvic examination requirements for hormonal contraception. Current practice vs. evidence. Journal of the American Medical Association 2001;285(17):2232-9.

10 Food and Drug Administration. Prescription drug products: certain combined oral contraceptives for use as postcoital emergency contraception. Federal Register 1997; 62: 8610-2.

11 Hannaford P. Cardiovascular events associated with different combined oral contraceptives: a review of current data. Drug Safety 2000;22(5):361-371.

12 Burkman R, Schlesselman JJ, Zieman M. American Journal of Obstetrics and Gynecology 2004;190:S5-22.

13 Petitti DB. Combination estrogen-progestin oral contraceptives. New England Journal of Medicine 2003;349(15):1443-50.

14 Petitti DB et al. for the WHO Study of Hormonal Contraception and Bone Health. Steroid hormone contraception and bone mineral density: a cross-sectional study in an international population. Obstetrics and Gynecology 2000; 95(5):736-44.

15 WHO. Selected practice recommendations for contraceptive use, second edition. Geneva, Switzerland, 2004.

16 Hatcher RA, Trussell J, Stewart F, et al., editors Contraceptive technology eighteenth revised edition. New York: Ardent Media, 2004.

17 WHO. Selected practice recommendations for contraceptive use, second edition. Geneva, Switzerland, 2004.

18 Hatcher RA, Trussell J, Stewart F, et al., editors Contraceptive technology eighteenth revised edition. New York: Ardent Media, 2004.

19 Morrison, Charles S et al.  Hormonal Contraceptive Use, Cervical Ectopy, and the Acquisition of Cervical Infections. Sexually Transmitted Diseases 2004; 31(9): 561-567.

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Resources
Green Contraception Brochure
The "Green Print" for Sustainable Contraceptive Research & Development
Hormonal Contraception and HIV: Is there a link? Updated 2012
This issue brief helps to answer some of the important questions about the relationship between hormonal contraception and HIV/AIDS based on the newest studies and information.
Updated Information About the Birth Control Patch
Learn more about Ortho Evra, the birth control patch

Is there estrogen from birth control in my water?
Find more resources and a new study by UCSF researchers

Implanon® FAQ
Learn more about Implanon/Nexplanon, a progestin-only implant that lasts up to three years.
Oral Contraceptives Over-the-Counter Working Group Statement of Purpose
The OC OTC Working Group is an informal coalition of reproductive health and rights organizations, researchers and prominent clinicians evaluating the risks and benefits of demedicalizing contraceptive care.
"New Studies, Old News: Oral Contraceptive Research in the Media
Two recent and separate studies have linked the use of oral contraceptives to a possible increased risk of heart disease and cervical cancer, respectively.  More research is still needed, but follow the link to learn more about what the findings might mean for women using or considering the use of oral contraception. [PDF, 145KB]

Choosing a Birth Control Method
These interactive tools from the Association of Reproductive Health Professionals and Bedsider help women choose a birth control method that is right for them.

Birth Control Within Reach
Executive summary of a national survey commissioned by Pharmacy Access Partnership on women's attitudes and interest in pharmacy access to hormonal contraception. For the full report, click here.
 
 
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