There are many different kinds of birth control—and even more factors contributing to decisions about the best birth control method for you or your partner. Some methods rely on the hormone progestin or a combination of estrogen and progestin hormones to be effective. Some methods are non-hormonal, including those that are used by men. Permanent methods include tubal ligation and vasectomy. In this blog, we will discuss contraceptives that use either progestin only or a combination of estrogen and progestin.
Some of the factors that people may consider are access and cost, whether the birth control method can be easily stopped if desired, and how the birth control method is used. It is important to note that no hormonal birth control method is effective against sexually transmitted infections or diseases.
Misha Pangasa, MD, a family planning fellow at the University of Utah, says, “The most effective birth control is the one that a person feels comfortable using regularly.”
Birth Control That Contains Progestin Only
Many types of birth control utilize only progestin, which causes the cervical mucus to thicken, preventing the sperm from traveling to fertilize the egg in the fallopian tube. It can also help prevent ovulation, but according to the American College of Obstetricians and Gynecologists (ACOG), four out of ten people will continue to ovulate while taking progestin.
Contraceptives that include only progestin, however, are safe even for people with a history of thromboembolism, hypertension, or those at higher risk of stroke. In general, progestin-only contraceptives are associated with more irregular bleeding patterns. For some people, continued use over time can stop bleeding altogether.
Birth Control Implant
Method: The birth control implant Nexplanon® is a thin rod that a health care provider inserts under the skin in the upper arm. It releases progestin.
Advantages: Nexplanon® lasts for five years but can be removed at any time and has an extremely low failure rate (~1/1000).
Changes to Period: As with other progestins, bleeding may be irregular and unpredictable, though some people have no bleeding at all.
IUD (Intrauterine Device)
Method: An IUD is a flexible piece of plastic shaped like a T that a health care provider inserts into the uterus. Four types of hormonal IUDs use progestin, and one nonhormonal one uses copper.
Advantages: Hormonal IUDs last anywhere from three to eight years. IUDs are extremely effective with failure rates of ~2-5/1000 and can be easily removed by a health care provider. The progestin in hormonal IUDs acts almost exclusively inside the uterus, with very little going throughout the body. This makes hormonal side effects less common. Typically, IUDs are easily removed by a health care provider in clinic; rarely, they can migrate or be difficult to remove. There is no delay in return to baseline fertility after removing.
Changes to Period: Bleeding patterns with progestin-only IUDs are typically light but may be unpredictable or irregular. Many people will have no bleeding by the end of the first year of use.
Depo-Provera Shot
Method: Two types of birth control injections are available: Depo-Provera® and Depo-SubQ 104®. Both injections must be administered every three months, but the regular Depo-Provera® is injected into the muscle, while the SubQ® is injected just under the skin.
Advantages: The SubQ® injection can be self-administered at home with a prescription, whereas the intramuscular injection must be given by a health care provider every 12 weeks.
Changes to Period: As with other progestins, bleeding may be irregular and unpredictable, but many people will have no bleeding by the end of the first year of use. Depo-Provera® is associated with a delay in return to ovulation and fertility after stopping, which may be a consideration for some people who are considering pregnancy soon after cessation.
Birth Control Pills
Method: Two progestin-only pills are currently available in the U.S.: Slynd® and Micronor®. Importantly, some progestin-only pills require a commitment to a precise daily schedule. With Micronor®, if a pill is taken outside of the same three-hour window every day, it may not be effective in preventing pregnancy, and a backup method should be used for seven days. With Slynd, backup is only needed if the pill is missed by more than 24 hours, but, because Slynd is a newer medication, many insurances do not cover it. According to ACOG, four out of ten people will continue ovulating when using the progestin-only pills.
Advantages: Unlike pills that include estrogen and progestin, the progestin-only pills do not increase the risk of high blood pressure or cardiovascular disease. You can take the progestin-only pills if you have certain medical conditions such as deep vein thrombosis or a history of hypertension. These pills are considered safe to use after pregnancy while breastfeeding and do not affect milk supply. Pills can easily be stopped without seeing a health care provider if someone wants to stop taking them. There is no delay in return to baseline fertility.
Changes to Period: As with other progestin-only contraceptives, bleeding may be irregular or unpredictable; your period may stop altogether.
Contraceptives That Include Both Estrogen and Progestin
In addition to effectiveness, the contraceptives containing both estrogen and progestin have several benefits, according to ACOG:
- Periods become shorter and lighter
- They help reduce menstrual cramps
- They decrease the risk of ovarian, uterine, and colon cancer
- They may improve acne
- They can be used to treat certain disorders like endometriosis
- They can prevent or lessen PMS, bone thinning, and cysts in the breasts and ovaries
Common side effects include:
- Spotting or bleeding between periods
- Soreness in breasts
- Nausea
- Headaches
According to the ACOG, these symptoms usually disappear after a few months. However, contraceptives that include both hormones may not be suitable for people older than age 35 who smoke or those with a history of high blood pressure, stroke, heart disease, breast cancer, or diabetes-related complications.
Birth Control Rings
Method: The NuvaRing® and Annovera® are flexible rings made from a silicone or thermoplastic that use estrogen and progestin to prevent pregnancy. The hormones are absorbed from the rings, through the vaginal tissue, into your body. The rings must be self-inserted into the vagina (much like a tampon) and removed on a schedule. The NuvaRing® is removed monthly and replaced with a new ring. NuvaRings® that won’t be used within four months must be refrigerated. The Annovera® ring lasts for a year but is kept in place for 21 days, then taken out for seven days (if a person would like to have a period), then replaced. It must be cleaned with soap and water when removed from the vagina. Also, only water-based lubricants may be used when the Annovera® ring is in place. While rings are highly effective if used properly, drawbacks include:
- The ring may be expelled and must be repositioned in the vagina
- Remembering to remove and replace the ring on schedule
- The possibility of vaginal discharge
- Toxic Shock Syndrome, a rare condition that is caused by certain strains of bacteria
Advantages: This method of birth control can be easily stopped should you decide you want to stop taking it.
Changes to Period: For people who prefer not to have periods, the rings can be used continuously to prevent withdrawal bleeding. For those who prefer to have periods, bleeding can be scheduled based on when the ring is taken out.
Birth Control Patch
Method: The two birth control patches available, Xulane® and Twirla®, use a combination of estrogen and progestin to prevent pregnancy and must be replaced weekly. They are usually placed on a person’s belly, butt, or back. Those using the Twirla® brand patch cannot spend more than 30 minutes at one time in the water.
Advantages: The patches are easy to place on dry, clean skin. You don’t have to remember a daily pill, and it’s possible to stop use to get pregnant. If used perfectly, the patch is 99% effective.
Changes to Period: Like the ring, patches can be used continuously to avoid periods. With both patches, a patch-free week after three weeks can provide a scheduled period.
Combined Hormonal Birth Control Pills
Method: Numerous types of birth control pills are available that include estrogen and progestin to inhibit ovulation and thicken cervical mucus. These come in many doses and types that must be taken daily.
Advantages: If used perfectly, these pills are 99% effective and can be easily stopped without seeing a health care provider. There is no delay in return to fertility.
Changes to Period: Most combined hormonal contraception pill packs include three weeks of estrogen and progestin pills and one week of placebo or “sugar” pills for scheduled bleeding. Like rings and patches, the placebo weeks can be used to have scheduled bleeding. Or they can be skipped and a new pack started to use the pills continuously and avoid bleeding.
Contraception as a Health Care Journey
Pangasa suggests that deciding on which contraceptive method to use is a “continuum or journey for people throughout their reproductive years.” She says that although health care providers can be guides and allies, ultimately patients must make decisions based on their values, preferences, and health, as well as where they are in their lives.