Birth Control

Patient's goal(s) in using birth control? (NOTE: If patient reports wanting to use for irregular bleeding, need to clarify type of irregular bleeding in case it warrants no prescription and in-person referral - for example, no period for 2 years, etc.)

What has patient used in the past for BC and did it work or not work? If it did not work, why not? Did they ever use anything they were happy with in the past?

Does the patient have a preferred birth control they would like to be prescribed?

Does patient plan to get pregnant in the next year? (concern here is Depo - may take up to a year to get pregnant after discontinuation)

Past medical history

Current medications

CV Risk Factor count: age >/= 40, BMI >/=30, nicotine use, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels

• ***Unless there is a medical contraindication that requires in-person follow-up, PVH will refill a one year supply of birth control during an encounter***

• Pregnancy Exclusion Criteria:  You can reasonably exclude pregnancy if no symptoms of pregnancy and any one of the following apply:

  • Within 7 days from onset of normal menses

  • No intercourse since last menses

  • Consistent, correct use of reliable contraception

  • Under 4 weeks postpartum

  • Fully/nearly fully breastfeeding, amenorrheic, and < 6 months postpartum

• Unless specifically requested, prescribe monophasic pills as first line and avoid tri-phasic pills (i.e. Tri-Sprintec)

• Higher estrogen = thicker uterine lining = heavier period.

  • If patient on low dose oral BC (</= 20mcg of estrogen), wants period and is not having it, increase estrogen

• Lower estrogen = thinner uterine lining = less bleeding/amenorrhea

• Doses based on estrogen content (EE = ethinyl estradiol):

  • High dose – over 35 mcg EE

  • Standard dose – 30 – 35 mcg EE

  • Low dose – 20 – 25 mcg EE

  • Very low dose – 10 mcg EE

• Progestins are considered more/less androgenic. More androgenic = more similar to testosterone

• Almost all oral CHC have the same type of estrogen (exception: Natazia, Nexstellis), therefore, consider type of progesterone when selecting pill based on patient goals:

• • Acne: technically all CHC (oral and non-oral) can help with acne. Takes 3-6 months to see full impact on acne and may not completely treat acne. Acne may worsen before it improves when starting or switching BC (typically for first 6-12 weeks). A pill that is more androgenic is more likely to worsen/not treat acne. Important to remember guidelines below, however, individuals may have their own response.

    • Drospirenone (i.e. Yaz, Yasmin, Slynd) first choice

    • Sprintec (norgestimate) second choice

    • Junel Fe (norethindrone) third choice

    • Levonorgestrel last choice (i.e. Aviane, Portia, Seasonique, unless has worked well in the past)

    • If patient using BC for acne, if < 3 months and has not seen desired improvement, reassure, continue to use. If > 3 months, or severe worsening of acne in first 1-2 months, recommend switch.

• • Breast Tenderness/Bloating

    • Hormones can cause fluid retention, causing a bloated feeling, accompanied with larger and fuller-feeling breasts, accompained by pain/tenderness

    • If < 3 months since starting new pill, reassure. Recommend supportive sports bra, staying hydrated, avoiding excess sodium

    • If no improvement > 3 months → provider may recommend switch in birth control 

    • IMPORTANT: Dependent on patient’s report, be mindful of any indication that there may be more going on needing in-person eval (i.e. asymmetrical swelling, skin dimpling/changes to the skin, nipple retraction/discharge, redness/hot to touch)

• • Cramping

    • Birth control can help reduce pain associated with menstrual cramps

    • Cramping during adjustment period (3 mo), can occur

    • Counseling recommendations + interventions:

      • If < 3 months → Reassure + counsel on pharmacological and/or natural remedies for analgesia (i.e. NSAIDs, Heating pads/Hot bath/Exercise)

      • If severe cramps; febrile; pain when not on or about to get period → recommend in-person evaluation to r/o that cramping isn’t sign of something else

• • Cycle Control/Persistent BTB on other pills

    • Levonorgestrel first choice (i.e. Aviane, Portia, Seasonique)

    • More androgenic pill = less BTB

    • BTB does not indicate decrease in efficacy - reflects tissue breakdown as endometrium adjusts to new, thin state.

    • BTB/Amenorrhea more common w/ low doses and skipping periods/extended cycles.

    • Missed pills is common cause

    • Brown discharge is normal both on and off BC. If accompanied by smell (malodorous) or pain - may be sign of infection. Common infections that cause dark-colored discharge are Chlamydia, Gonorrhea and Bacterial Vaginosis (BV).

    • First need to confirm:

      • If taking pills on time

      • Trying to skip periods in first 3 months of starting a new pill (not recommended)

      • New meds/supplements (St. John's Wort common cause)

      • Smoking

      • Post-coital bleeding only (BTB exclusively during/after sex - not normal or expected - may be a sign of infection)

      • Using a tri-phasic pill (switch to monophasic)

      • Bleeding from placebos into Week 1 (increase estrogen)

    • If patient concerned about "abnormal bleeding", need to:

      • Quantify bleeding (how many pads/tampons per hour are completely soaked)

      • Quarter-sized clots can occur, and generally are not cause for worry

      • Ask about other s/sx of acute blood loss

      • If patient’s bleeding is excessive - enough to fill 1 tampon or pad per hour, for 2-3 hours in a row, if they see blood clots more than the size of a quarter or larger, and especially if patient starts to feel dizzy or lightheaded on account of the bleeding, patient should STOP the pill and seek immediate in-person medical attention

• • Decreased Libido

    • Theory: Hormonal contraceptives suppress ovarian androgen production and increase sex hormone-binding globulin (SHBG), reducing free testosterone levels. Testosterone greatly influences sexual desire and lubrication. Antiandrogenic progestins (e.g., drospirenone) may have more pronounced effects on vaginal blood flow and lubrication compared to androgenic progestins, though both types reduce physiological arousal relative to naturally cycling women. 

    • Rule out other causes of decreased libido (i.e. relationship satisfaction, underlying medical issues, etc)

    • Depo injection, vaginal ring, Nexplanon highest association with decreased libido in studies

    • Consider change in progesterone to more androgenic version (no evidence to show one pill superior to another)

    • Consider non-hormonal method (no systemic hormone)

    • Consider hormonal IUD or traditional POP (norethindrone or OPill), which have less systemically circulating hormon

    • Consider higher estrogen method (higher estrogen pill or patch)

• • Hair changes

    • If hair loss on the head is a concern, first rule out other causes of hair loss.

    • If unwanted hair growth is a concern (i.e. chin, chest, etc.), first rule out other causes of unwanted hair growth.

    • If no underlying condition suspected, follow same guidelines as for acne with less androgenic options.

    • Hair regrowth will take 3-6 months.

    • Unwanted hair will not be removed with BC, but can prevent new unwanted hair from growing.

• • Headaches (pre-menstrual) & Migraines

    • May be due to drop in estrogen

    • Consider: low dose (</= 20mcg estrogen), monophasic, 24/4 vs. 21/7 (less placebo days = less days without estrogen), skipping periods

    • Lo Loestrin is low dose, and only has 2 placebo pills (see coupon below, is expensive with no generic)

    • Counseling Recommendations & Interventions

      •  If patient reports SEVERE headache (like nothing ever experienced), & no previous history has been reported, probe further as needed & refer out for local evaluation.

        • Consider stopping BC or changing to POM/no-hormone method pending in-person eval

      • If not severe and < 1-3 months

        • Confirm no auras (may need change to POM if present)

        • Recommend NSAID PRN, if not allergic

        • If no improvement after 1 month, consider switching to a lower dose pil

• • Mood lability

    • Hormones & mood state variability have been extensively linked in studies; remains largely inconsistent. Over time, birth control can help to reduce the lability of hormone levels

    • Start with low dose (</= 20mcg estrogen), monophasic

• • Nausea

    • Estrogen can irritate the stomach; some studies have shown both estrogen/progestin slow gastric emptying by relaxing stomach muscles, leading to nausea/gastric upset

    • Counseling recommendations:

      • If < 1 month since starting new pill, take at nighttime or with meals

      • If no improvement > 1 month → switch to a lower dose option

    • Nausea/stomach upset may be severe enough to induce vomiting or diarrhea

      • Counseling recommendations + interventions similar to a “missed” pill If vomiting within 2 hours of dose (significant chance pill was not absorbed) or experiencing watery, loose stools for >24 hours (decreased absorption likely)

      • Goal is to get them back on track ASAP, dependent on what their discomfort allows

    • IMPORTANT: any patient that has been on their birth control > 3 months, and is ℅ about nausea for 1st time - possibility of unplanned pregnancy, ask about UPI and missed pills in current/previous pack + other common early pregnancy symptoms (breast tenderness/changes, unexplained fatigue, food or smell aversions), may recommend a home pregnancy test

• • PCOS

    • These patients need PROGESTERONE, not estrogen - already typically have high systemic estrogen

    • Consider patient goals - acne, hair growth, weight gain are typical

    • Start with low dose (</= 20mcg estrogen), monophasic

• • Skipping Period

    • Can use any BC to skip periods, does not need to be pill specifically designed for this (like Seasonique/Seasonale)

      • Extended cycle pills are typically more androgenic

    • Monophasic only (no tri-phasic unless used successfully in the past)

    • Higher estrogen pill (>20mcg estrogen), higher risk of BTB/need to take a "break" from skipping periods more often

    • Counsel for realistic expectations!

      • BTB x 12 weeks can be normal

      • Recommend taking placebos/having periods for first 3 months to reduce BTB chances, then can try skipping per below.

      • If using non-extended cycle pill, recommend:

        • Take active pills for at least 21 days, plus however long they can or want to before spotting becomes bothersome.

        • Then stop for 4-7 days for period (can either take placebos or not)

        • Then repeat. 

        • Can likely extend time between periods the longer they use a pill, anecdotal average about 10-14 weeks between periods

      • IMPORTANT: some patients may never be able to skip a period without BTB on any method. Rare, but possible.

• • Weight gain/Water Retention

    • Only BC definitively linked to weight gain is Depo, and this is only true for about 10% of patients. DMPA (depot medroxyprogesterone Acetate) is thought to:

      • Decrease metabolism → increased fat storage

      • Increased appetite → Increased caloric intake

      • Other possible mechanisms include changes to how the body breaks down carbohydrates, interference with insulin action

    • Most weight gain is d/t water retention and, usually resolves within first 3 months

    • May need some trial and error in finding the right BC

    • Start with low dose (</= 20mcg estrogen), monophasic if concerned

  • Yeast Infection

• • • BC can disrupt natural balance of hormones already present, leading to yeast overgrowth/infection

    • Some women are more prone, even w/standard dose BC

    • Most common s/s, include:

      • Vaginal dryness/pain during intercourse

      • Burning around vaginal opening

      • Vaginal itching and general discomfort

      • Swelling or irritation of vulva and external parts of vagina

      • White, clumpy, and thick vaginal discharge

    • Counseling recommendations + Interventions

      • Assess s/s to r/o other possible infection

      • Possibly recommend different BC or next steps (i.e. refer out for in-person care)

Google Doc Linked Here for POM vs. CHC vs. Non-Hormonal/Refer out Conditions

Link to CDC MEC Eligibility Criteria (PDF condensed chart)

Link to *full* CDC MEC Guidelines (2024)

Category A

• Oral CHC and the Slynd POP are likely to be effective for pregnancy prevention after the GLP dose has stabilized.

• Counseling:

  • Back-up contraception is recommended for FOUR weeks after initiation of a GLP and for FOUR weeks after each increase in GLP dose.

Category B

• Norethindrone and Opill POPs are unlikely to be effective for pregnancy prevention with concurrent use of any of these GLPs, because of the narrow dosing window for Norethindrone and Opill.

• Counseling:

  • Back-up contraception recommended for entire duration of GLP use.

  • If eligible, Slynd may be preferred for better contraceptive efficacy.

  • Consider recommending LARC, if appropriate

Category C

• All birth control pills may be less effective for pregnancy prevention if daily dose is taken AFTER these GLPs, due to slowed absorption of oral meds.

• Counseling:

  • All birth control pills should be taken at least ONE HOUR PRIOR to daily GLP administration

More Information about GLPs & Oral BC

• Interaction between BC/GLP caused by slowed absorption (vomiting also a concern)

• GLP-1 medicines do not affect birth control methods that arenʼt a pill (Depo, patch, ring, Nexplanon, IUD)

• Some research coming out supporting tirzepatide as most problematic when used with oral BC when compared to other GLPs

• Some research has shown semaglutide and dulaglutide may not interfere with traditional dose COC

WHEN TO START

• Anytime if no risk of pregnancy, use back-up or abstain from intercourse for 7 days after starting for pregnancy protection, unless...

• If starting Day 1 - Day 5 of next period, pregnancy protection immediate, less chance of BTB

HOW TO TAKE BIRTH CONTROL

• Take 1 pill at the exact same time each day

COMMON SIDE EFFECTS 

• Nausea, breakthrough bleeding, sore breasts, bloating and mild headaches when starting BC, typically lasts about 1 month.

• Unscheduled bleeding during the active pills - whether heavy/light, early/late, skipped periods/multiple periods, brown/red blood, clots/no clots - is common and normal. It doesn’t indicate anything else is wrong – it’s just the body getting used to the new hormones. Patient should continue taking pill at the same time each day.

• It may take up to three packs/months before establishing a predictable bleeding pattern.

• If breakthrough bleeding continues (or starts) after 3 months, continue pill and contact PVH or GYN.

LATE OR MISSED PILLS

• If 1 pill less than 24 hours late, take late pill immediately, which may mean taking 2 pills in one day; no back-up method needed; EC not needed

• If 1 pill missed (24 to <48 hrs late), same as above

• If missing 2 pills during week 1 or week 2: take yesterday’s pill as soon as possible, then take today’s pill at usual time. Continue with current pack and take one pill a day, from then on.  Use back up contraception for 7 days; consider EC if had unprotected intercourse during missed pill days

• If missing 2 pills during week 3: same as above, and recommend skipping placebo pills and go to new pack after finishing active pills in last week. 

• If missing 3 or more pills during week 1 or week 2: take yesterday’s pill as soon as possible, then take today’s pill at usual time. Discard any missed pills from before yesterday. Continue with current pack and take one pill a day, from then on.  Use back-up contraception for 7 days; consider EC if had unprotected intercourse during missed pill days

• If missing 3 or more pills during week 3: same as above, and recommend skipping placebo pills and go to new pack  after finishing active pills in last week.

• NOTE: Ella and CHC will counteract each other and should not be taken at the same time. PlanB can be taken at the same time.

ADVERSE EFFECTS

Go to the ER right away if noticing:

• Sudden leg pain or swelling (especially in one leg)

• Chest pain or sudden shortness of breath

• Severe headache that is different from any usual headaches

• Sudden vision changes or trouble speaking

• Abdominal pain (severe, unexpected pain or cramping) 

Presentation here

XULANE: WHEN TO START

• Anytime if no risk of pregnancy, use back-up or abstain from intercourse for 7 days after starting for pregnancy protection, unless...

• If starting Day 1 - Day 5 of next period, pregnancy protection immediate

TWIRLA: WHEN TO START

• Anytime if no risk of pregnancy, use back-up or abstain from intercourse for 7 days after starting for pregnancy protection, unless...

• 1st day of period (within 24 hours), pregnancy protection immediate

HOW TO USE

• Change patch once a week on the same day of the week for 3 weeks

• Recommend rotating the area of placement to avoid irritation (avoid breast area, recommend upper arm, over shoulder blade, upper glute, along front bikini line)

• Check the patch each day to ensure good adhesion

• After 3 weeks of wearing patches, remove the patch and have 1 week patch-free (Period starts during patch-free week)

• Continuous use on patch not recommended due to increased estrogen concentration and possible increased blood clot risk. It is an off label recommendation that has not been studied for safety.

XULANE: LATE OR MISSED PATCH OR PATCH FELL OFF

• More than 1 day late restarting the patch after period week: apply the patch as soon as possible; use backup contraception for 7 days; the first day the patch is applied is day 1 of the new patch cycle

• 1-2 days late changing the patch for week 2 or 3: remove the current patch and apply the new patch right away; use backup contraception for 7 days; change the next patch on the regular patch change day

• Patch fell off for less than 24 hours: try to re-apply the patch that fell off or apply a new one ASAP

• Patch fell off for more than 24 hours: apply a new patch ASAP; this new patch is the start of a new 4-week cycle with a new patch change day; use backup contraception for 7 days

TWIRLA: LATE OR MISSED PATCH OR PATCH FELL OFF

• At the start of any cycle (week 1 / day 1 ): apply new patch immediately. This becomes the new “patch change day” and “day 1” of the cycle. Use backup contraception for 7 days

• In middle of cycle (week 2 OR week 3), for 1 or 2 days (up to 48 hours): apply new patch immediately. The next patch should be applied on the usual “patch change day” No backup contraception needed

• > 2 days (48 hours or more): stop the current contraceptive cycle. Start a new 4 week cycle immediately. This becomes the new “patch change day” and “day 1” of the cycle. Use backup contraception for 7 days

• At the end of cycle (week 3): if forgot to remove patch, remove patch ASAP. Next cycle should start on usual “patch change day." No backup contraception needed. Essentially will result in shorter period week.

COMMON SIDE EFFECTS 

• Nausea, breakthrough bleeding, sore breasts, bloating and mild headaches when starting BC, typically lasts about 1 month.

• Unscheduled bleeding during the active pills - whether heavy/light, early/late, skipped periods/multiple periods, brown/red blood, clots/no clots - is common and normal. It doesn’t indicate anything else is wrong – it’s just the body getting used to the new hormones. Patient should continue taking pill at the same time each day.

• It may take up to three packs/months before establishing a predictable bleeding pattern.

• If breakthrough bleeding continues (or starts) after 3 months, continue pill and contact PVH or GYN.

ADVERSE EFFECTS

Go to the ER right away if noticing:

• Sudden leg pain or swelling (especially in one leg)

• Chest pain or sudden shortness of breath

• Severe headache that is different from any usual headaches

• Sudden vision changes or trouble speaking

• Abdominal pain (severe, unexpected pain or cramping) 

WHEN TO START

• Anytime if no risk of pregnancy, use back-up or abstain from intercourse for 7 days after starting for pregnancy protection, unless...

• If starting Day 1 - Day 5 of next period, pregnancy protection immediate, less chance of BTB

HOW TO USE BIRTH CONTROL

• Insert ring and leave the ring in place for 3 full weeks

• After 3 weeks of wear, on the same day of the week the ring was inserted, remove the ring and have 1 week ring-free

• Place used ring in the foil pouch it came in, seal the pouch, and throw it away in the trash away from young children and/or pets

• Period starts during ring-free week

LATE OR MISSED RING

• Ring removed/fell out for less than 3 hours: Gently rinse the ring under cool water and reinsert in vagina ASAP

• Ring removed/fell out for greater than 3 hours: Gently rinse the ring under cool water and reinsert in vagina ASAP; use backup contraception for 7 days

• Forgot to take the ring out at end of 3 weeks: Okay to leave the ring in for up to 4 weeks; remove the ring, throw it away, and wait 1 week before inserting a new ring

• Less than 48 hours late inserting new ring after ring-free week: Insert the new ring ASAP; consider emergency contraception; keep ring in place for 3 weeks

• More than 48 hours late inserting new ring after ring-free week: Insert the new ring ASAP; consider emergency contraception; use backup contraception for 7 days; keep ring in place for 3 weeks

• NOTE: Ella and CHC will counteract each other and should not be taken at the same time. PlanB can be taken at the same time.

COMMON SIDE EFFECTS 

• Nausea, breakthrough bleeding, sore breasts, bloating and mild headaches when starting BC, typically lasts about 1 month.

• Unscheduled bleeding during the active pills - whether heavy/light, early/late, skipped periods/multiple periods, brown/red blood, clots/no clots - is common and normal. It doesn’t indicate anything else is wrong – it’s just the body getting used to the new hormones. Patient should continue taking pill at the same time each day.

• It may take up to three packs/months before establishing a predictable bleeding pattern.

• If breakthrough bleeding continues (or starts) after 3 months, continue pill and contact PVH or GYN.

ADVERSE EFFECTS

Go to the ER right away if noticing:

• Sudden leg pain or swelling (especially in one leg)

• Chest pain or sudden shortness of breath

• Severe headache that is different from any usual headaches

• Sudden vision changes or trouble speaking

• Abdominal pain (severe, unexpected pain or cramping) 

WHEN TO START

• Anytime if no risk of pregnancy, use back-up or abstain from intercourse for 7 days after starting for pregnancy protection, unless...

• If starting Day 2 - Day 5 of next period, pregnancy protection immediate, less chance of BTB

HOW TO USE BIRTH CONTROL

• Single-use ring that lasts 13 cycles

• Skipping periods with Annovera is considered an off-label use, has not been studied, unknown if enough medication to skip periods

• Leave the ring in place for 3 full weeks

• After 3 weeks of wear, on the same day of the week the ring was inserted, remove the ring and have 1 ring-free week.

• Period should start during ring-free week, usually 2-3 days after ring is removed

• Wash ring with mild soap and warm water, pat dry with clean cloth towel or paper towel, and store in its case for 7 days (does not need refrigeration) 

• Ring should be cleaned prior to re-inserting into vagina for another 21 continuous days.

LATE OR MISSED RING

• Ring removed/fell out for less than 2 hours: Gently rinse the ring under warm water and reinsert in vagina ASAP

• Ring removed/fell out for greater than 2 hours at one time - or at different times that add up to more than 2 hrs over the 21 days of continuous use: Gently rinse the ring under warm water and reinsert in vagina ASAP; use backup contraception for 7 days

• Forgot to take the ring out at end of 3 weeks: Remove ring for 7 days, and reinsert it for 21 days to resume the 21-to-7 schedule

COMMON SIDE EFFECTS 

• Nausea, breakthrough bleeding, sore breasts, bloating and mild headaches when starting BC, typically lasts about 1 month.

• Unscheduled bleeding during the active pills - whether heavy/light, early/late, skipped periods/multiple periods, brown/red blood, clots/no clots - is common and normal. It doesn’t indicate anything else is wrong – it’s just the body getting used to the new hormones. Patient should continue taking pill at the same time each day.

• It may take up to three packs/months before establishing a predictable bleeding pattern.

• If breakthrough bleeding continues (or starts) after 3 months, continue pill and contact PVH or GYN.

ADVERSE EFFECTS

Go to the ER right away if noticing:

• Sudden leg pain or swelling (especially in one leg)

• Chest pain or sudden shortness of breath

• Severe headache that is different from any usual headaches

• Sudden vision changes or trouble speaking

• Abdominal pain (severe, unexpected pain or cramping) 

https://docs.google.com/spreadsheets/d/1E9ulVJOeuHfQXbME7wRl9NRY7HJUzGam/edit?pli=1&gid=807781940#gid=807781940 

There are savings coupons for many expensive birth controls that patients can use at in-person pharmacies (best) and some online pharmacies (more difficult):

• Annovera (CHC annual ring): https://www.annovera.com/annovera-cost-coupon/

• Balcoltra (CHC pill): https://balcoltra.com/assets/images/coupon.pdf

• Femlyv (ODT): https://accessactivation.apollocare.com/millicent/femlyv/download_pdf 

• Lo Loestrin (CHC pill): https://www.loloestrin.com/savings-card

• Nexstellis (CHC pill): https://www.nextstellis.com/nextstellis-coupon-savings/

• Phexxi/Phexx (non-hormone vaginal gel): https://phexx.com/savings-program-enrollment

• Slynd (POP pill): https://slynd.com/slynd-patient-savings-program/

• Twirla (CHC patch): https://www.twirla.com/savings-program/