Contraceptives: Uses, common brands, and safety info

Contraceptive drugs have been used to prevent pregnancy since the 1960s. Since then, the use of contraceptive drugs has become widespread, and the number of contraceptive options has increased dramatically. The use of birth control is a highly personal choice, and it is easy to feel overwhelmed by the many types of birth control available today. In this article, we will review the different kinds of contraceptive drugs, including how they work, what conditions they treat, the many brand names, and their cost, side effects, and safe use.

What are contraceptives?

Contraceptives, also referred to as birth control, are methods used to prevent pregnancy. Most methods of contraception involve the administration of a drug in the form of a tablet, skin patch, injection, or implant. Nearly all contraceptive drugs fall under the category of hormonal contraception, meaning they contain hormones that alter the functioning of the female menstrual cycle. An example of a non-hormonal method is a copper IUD, which uses copper implanted in the uterus to prevent pregnancy. Non-drug forms of contraception such as barrier methods (i.e. male condoms and female condoms) are not covered in this article.

How do contraceptives work?

The menstrual cycle lasts on average 28 days in total. This cycle includes several different phases. After menstruation, two hormones called follicle-stimulating hormone (FSH) and luteinizing hormone (LH) increase, which causes follicles in the ovary to mature and the lining of the uterus to thicken. Next, an estrogen called estradiol will rise steadily until about halfway through the cycle, at which point it will drop sharply (around day 14). This drop in estradiol triggers a surge in FSH and LH, which causes a mature egg to be released from the ovary into the fallopian tube (ovulation). This ovulation phase is the only time during the menstrual cycle that pregnancy can occur.

Since the surge in FSH and LH are required to begin the ovulation phase, blocking their effects can prevent the release of a mature egg. If there is no egg present in the fallopian tube to be fertilized, pregnancy cannot occur. So how do contraceptives prevent FSH and LH from triggering ovulation? When estradiol and progesterone levels are high, FSH and LH cannot spike and so ovulation does not occur. Most contraceptives work by creating this hormonal state. They increase levels of estradiol and/or a synthetic progestin (i.e. norethindrone, levonorgestrel, norgestimate, etonogestrel, etc.) that mimics progesterone. Not only does this prevent ovulation, but also thickens cervical mucus and alters the lining of the uterus. These two changes help prevent fertilization and implantation, two important processes required for pregnancy to occur.

What are contraceptives used for?

Generally, contraceptives are used to prevent pregnancy. However, certain contraceptives can also be used to treat other conditions. For example, four combined oral contraceptives (Yaz, Ortho Tri-Cyclen, Beyaz, and Estrostep Fe) have FDA approval for the treatment of acne. Certain combined oral contraceptives are also FDA-approved for premenstrual dysphoric disorder (PMDD). Many contraceptives are used ‘off-label’ to treat the conditions below:

• Polycystic ovary syndrome (PCOS)

• Endometriosis

• Adenomyosis

• Hirsutism

• Absence of menstruation

• Menstrual cramps

• Menstrual migraine

• Excessive menstrual bleeding

• Menstruation-related anemia

• Painful menstruation

Types of contraceptives

Contraceptives come in many forms, including pills, injections, patches, and implants. There are many differences between the types of contraceptives, even among the different types of pills. Below is a brief overview of the different types of contraceptives. For a more detailed description of the different kinds of birth control pills, refer to this birth control guide.

Combined oral contraceptives (COC)

Combined oral contraceptives (COCs) are the most commonly used form of birth control. These pills contain a form of estrogen called estradiol, as well as a progestin. Progestins are artificial versions of the naturally occurring female hormone progesterone. COCs are often referred to as “the pill.” When taken as prescribed, they are more than 99% effective at preventing pregnancy. Typical use of COCs involves taking “active” pills for twenty-one days followed by “inactive” pills for seven days. Newer formulations might have twenty-four days of active pills followed by four days of inactive pills. The inactive pills simulate an average menstrual cycle and allow for menstrual bleeding to occur. The active pills continue to prevent pregnancy while the patient is taking the inactive pills. Some brands also contain iron to combat the possibility of becoming anemic from menstrual bleeding.

Examples of COCs:

• Apri

• Blisovi

• Cryselle

• Estarylla

• Kariva

• Lessina

• Loestrin

• Ocella

• Ortho Cyclen

• Previfem

• Seasonale

• Seasonique

• Sprintec

• Syeda

• Yaz

• Yasmin

Mini-pill (progestin-only oral contraceptive)

The mini-pill is a popular choice for women who cannot take estrogen, since it only contains a progestin. It may have fewer side effects for this reason. For example, it is a recommended alternative to COCs during breastfeeding because it does not change milk production. One important consideration is that the mini-pill must be taken at the same time every day to remain effective. Missing the window by even three hours requires the use of a backup form of birth control for at least two days. The mini-pill is slightly less effective than combination oral contraceptive pills. One reason for the higher failure rate is the need for precise timing of the mini-pill.

Examples of progestin-only pills:

• Camila

• Errin

• Heather

• Jolivette

• Jencycla

• Norlyda

Vaginal rings

Vaginal rings are small, flexible plastic rings that are inserted into the vagina for three weeks, then removed for one week. They contain a combination of estrogen and progestin just like COCs. The hormones work to prevent pregnancy by the same mechanisms, only the hormones are absorbed through the vaginal lining. Some vaginal rings can be inserted less frequently, such as every five weeks, and do not require a week off between uses. When used correctly, vaginal rings are as effective as COCs at preventing pregnancy.

Examples of contraceptive vaginal rings:

• Annovera

• EluRyng

• Nuvaring

Progestin subdermal implant

The progestin implant Nexplanon is a small rod inserted under the skin of the upper arm. It contains 68 mg of a progestin called etonogestrel, which is constantly released into the bloodstream in very small amounts. Once inserted, Nexplanon continues to protect against pregnancy for three years and can be removed at any time if a patient wishes to become pregnant. Nexplanon is more effective than the pill since it eliminates the possibility of missing a dose or other incorrect uses.

Intrauterine devices (IUDs)

There are two types of IUDs; copper and hormonal devices. Copper IUDs create an environment in the uterus and fallopian tubes that is toxic to sperm, which prevents sperm from reaching and fertilizing an egg. Hormonal IUDs contain a progestin called levonorgestrel, which is a common ingredient in many birth control pills. It is released into the uterus where it causes thickening of cervical mucus, thinning of the uterus lining, and inhibits sperm movement. It may also prevent ovulation. Like the progestin implant Nexplanon, IUDs are long-acting; they are inserted one time and continue to provide protection against pregnancy for three to ten years, depending on the type of IUD. For this reason, they are also more effective than oral contraceptives.

Examples of IUDs:

• Paragard (copper)

• Mirena (levonorgestrel)

• Kyleena (levonorgestrel)

• Liletta (levonorgestrel)

• Skyla (levonorgestrel)

Emergency oral contraceptives

Emergency contraception pills, commonly referred to as the “morning after pill,” are taken after unprotected sex. Despite this name, emergency contraceptive pills should be taken as soon as possible. While they can be used up to five days after unprotected sexual intercourse, they are more effective when taken sooner. Emergency contraceptive pills contain levonorgestrel or ulipristal acetate. Ulipristal is the more effective option, with an effectiveness of approximately 62-85%.These work by preventing or delaying ovulation and may also prevent fertilization if ovulation has already occurred. Levonorgestrel-containing products are available over the counter, while ulipristal-containing products require a prescription. Emergency contraception is not the same as an abortion pill; there is no evidence to suggest that either levonorgestrel or ulipristal acetate have any action that works after an egg is fertilized.

Examples of emergency oral contraceptives:

• Plan B (levonorgestrel)

• Aftera (levonorgestrel)

• Next Choice One Dose (levonorgestrel)

• My Way (levonorgestrel)

• Take Action (levonorgestrel)

• Ella (ulipristal)

Who can take contraceptives?

Most women can safely use contraceptives from the age that their menstrual cycle begins up until menopause. Women over 35 years old who smoke should not use oral contraceptive drugs due to the increased risk of blood clots and stroke. Contraceptives containing estrogen should not be used in women with a history of blood clots, stroke, cardiovascular disease, or peripheral vascular disease. Contraceptives should never be used while a woman is known or suspected to be pregnant, even if the contraceptive is being used for an indication other than birth control.

Are contraceptives safe?

For most women, contraceptives are safe to use and may even offer protective effects against certain types of cancer. However, there are certain conditions that may make certain contraceptives inappropriate for some women.

Depo-Provera carries a black box warning about significant bone mineral density loss, which increases with prolonged use. It is unknown if use during adolescence or early adulthood can impact peak bone mass and increase the risk of osteoporotic fractures in later life. Loss in bone mineral density from Depo-Provera may not be completely reversible.

Contraceptives containing estrogen and/or progestin, including non-oral formulations, increase the risk of blood clots and stroke. They carry a black box warning explaining that the risk of experiencing serious cardiovascular side effects increases with age and the number of cigarettes smoked.

Xulane and Zafemy carry a black box warning stating that women with a body mass index (BMI) greater than 30 have an increased risk of blood clots in the veins (venous thromboembolism) while using these two medications.

Hormonal contraceptives and IUDs do not protect against sexually transmitted infections/diseases (STIs/STDs).

Recalls

1. Apotex Corp. voluntary recall of ethinyl estradiol 30 mcg/drospirenone 3 mg due to empty blister pockets and incorrect ordering of the pills inside the package (March 1, 2019).

2. Jubilant Cadista Pharmaceuticals Inc. voluntary recall of ethinyl estradiol 20 mcg/drospirenone 3 mg due to out-of-specification dissolution results. Poor dissolution results can decrease absorption and decrease the effectiveness of the drug (July 23, 2019).

Restrictions

Women who have a history of a hypersensitivity reaction to the active ingredient or any component of a contraceptive drug should not use the offending product. Consult with a healthcare provider about the safe use of an alternative contraceptive drug.

Women cannot use Nexplanon if they have liver disease or a liver tumor, unexplained vaginal bleeding, breast cancer (or any other cancer that is sensitive to progestin) now or in the past, or are allergic to anything in Nexplanon.

Contraceptives containing estrogen and progestin combinations should not be used in smokers greater than 35 years of age. These include non-oral formulations such as transdermal patches (Xulane, Zafemy) and vaginal rings (NuvaRing, Eluryng, Annovera).

Women with a BMI greater than or equal to 30 kg should not use Xulane or Zafemy transdermal patches.

Hormonal IUDs should not be used in women with a congenital or acquired uterine anomaly that distorts the uterine cavity, acute pelvic inflammatory disease (PID), postpartum endometritis or infected abortion in the past three months, known or suspected breast, uterine or cervical cancer, uterine bleeding of unknown cause, untreated acute cervicitis, vaginitis or lower genital tract infections, acute liver disease or a liver tumor. Copper IUDs have similar restrictions but may be used if there is known or suspected breast cancer. Copper IUDs should also not be used in patients with Wilson’s disease or hypersensitivity to copper or other components of Paragard.

All forms of contraceptive drugs should be used with caution or avoided altogether in women who meet any of the following criteria:

• Breast cancer or other progestin or estrogen-dependent cancer

• Liver tumor

• Cerebrovascular or coronary artery disease

• Clotting disorder or history of blood clots

• Impaired liver function

• History of renal disease

• Smoking

• Diabetes/high cholesterol

• Migraines with aura

Can you take contraceptives while pregnant or breastfeeding?

Contraceptives should not be used during pregnancy as they can cause ectopic pregnancy, spontaneous abortion, and preterm labor. Contraceptives containing estrogen should not be used while breastfeeding within six weeks postpartum, due to the possible risk of infant gynecomastia and decreased milk production. Progestin-only pills (the mini-pill) are considered to be a safer option while breastfeeding.

Are contraceptives controlled substances?

No, contraceptives are not considered controlled substances.

Common contraceptives side effects

Not all contraceptives will have the same side effects due to differences in their active ingredients and route of administration. However, there are some side effects that are common to most contraceptive drugs. Consult your healthcare provider or pharmacist so you can minimize specific side effects that you may experience while taking contraceptives.

Common side effects of contraceptive drugs include:

• Spotting (irregular bleeding between periods)

• Breast tenderness

• Breast enlargement

• Headaches

• Changes in mood

• Changes in libido

• Weight gain or loss

• Fluid retention

• Bloating or abdominal cramps

• Visual changes with contact lenses

• Nausea

• Missed periods

• Changes in vaginal discharge

If you experience an allergic reaction and have symptoms of difficulty breathing, swelling of the throat or tongue, hives, or rash, seek medical attention right away.

How much do contraceptives cost?

The cost of contraceptives varies depending on the type formulation and the brand name. Most generic versions of combination oral contraceptives range from $30-$50, but they can be much less expensive with a SingleCare coupon. For example, Microgestin 1/20 costs around $109 for the brand, $32 for the generic, and as little as $4 with a SingleCare coupon. 

Whether you are uninsured or have prescription drug coverage, check out SingleCare coupons for discounts on contraceptives. While many insurance plans cover contraceptives, your out-of-pocket costs may still be less expensive with a SingleCare coupon.

Resources:

• Birth control ring

• Contraception choices in women with underlying medical conditions

• Depo-Provera full prescribing information

• Emergency contraception

• Emergency contraception: A last change to prevent unintended pregnancy

• How a Mirena IUD Works

• How effective is the birth control ring?

• How emergency contraception works

• When women can stop using contraceptives

• Mirena prescribing information

• Nexplanon prescribing information

• Oral contraceptives and cancer risk

• Paragard prescribing information

• Physiology, menstrual cycle

• Progestin-only contraceptives

• Understanding the IUD

• What is Nexplanon