Birth Control Pills (BCPs)

What are birth control pills?

Birth control pills or oral contraceptive pills have been used in this country for over 50 years. Safe and effective, they are one of the most extensively studied medications in the US. The first birth control pill, Enovid, was introduced in 1960. Since then, over 100 variations have become available. Birth control pills have changed significantly since their introduction. Most importantly, the dosages of the pills have been markedly reduced. As the dosages have decreased, the side effects have also decreased.

How do birth control pills work?

Most birth control pills contain two hormones: estrogen and progesterone. These hormones are synthetic versions of naturally occurring female hormones. They work primarily by preventing ovulation, and also help to prevent pregnancy by thinning the lining of the uterus and thickening the mucus on the cervix (the neck of the uterus). There are several types of pill packs:

  • 28 day pill packs: 3 weeks of active hormone pills and 1 week placebo pills
  • 21 day pill packs: 3 weeks of active hormone pills only.
  • 24 day pill packs: 24 days of active pills and 4 days of placebo pills.
  • "Seasonal" packs: Pill packs with 11 weeks of active pills and 1 week of placebo pills.

Pills can be monophasic, with all pills containing the same dosage. Theer are also multiphasic pills (most commonly triphasic) contain slightly different amounts of hormone throughout the active pills. Monophasic and multiphasic pills are equally effective.

Unless you are taking your pill packs "back to back" without a placebo break, your period occurs each cycle, a few days after completing the active pills.

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How effective are birth control pills in preventing pregnancy and STIs?

Birth control pills are 98% to 99% effective for women who take the pills every day as directed. Pill taking mistakes decrease effectiveness and, because of user error, the typical effectiveness of pills in the first year of use is 91%. There are detailed instructions on late or missed pills in the FAQ section below.

Birth control pills do not offer any protection against sexually transmitted infections (STIs). We recommend using condoms with birth control pills to protect against sexually transmitted infections.

What are the benefits of taking birth control pills?

Regular cycles
Birth control pills can regulate the menstrual cycle, and this is especially helpful for women with periods that come too often or too infrequently.

Reduced menstrual cramps and bleeding
Birth control pills can offer significant relief to women with painful menstrual cramps. They also reduce the amount of blood flow during the period. Less blood loss is helpful in preventing anemia.

Acne
We have known for years that birth control pills can improve some women's acne. There are a few heavily marketed brands that are felt to be beneficial for acne. Some women have a marked improvement, others less. If this is a concern for you, discuss it with your provider.

Other important benefits
The risk of developing benign breast cysts, ovarian cysts, pelvic inflammatory disease, and tubal pregnancy are reduced by taking birth control pills. Birth control pills also are associated with a markedly decreased risk of uterine cancer and ovarian cancer.

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What are the side effects of birth control pills?

Like all medicines, birth control pills have possible side effects that you need to be aware of. There are minor side effects and also rare but serious side effects.

Minor side effects of BCPs:

Nausea
Some women experience some mild nausea when first starting birth control pills. Usually this goes away within a short time. Taking your pill with food or taking it before bedtime may help. If you have persistent problems or unusually severe nausea, contact your provider.

Breast tenderness or enlargement
Mild breast tenderness or enlargement may occur after starting birth control pills. The tenderness can be reduced by decreasing your caffeine and salt intake and by wearing a bra with good support. Usually it gets better within a few weeks. If you notice persistent discomfort or a discrete lump, make an appointment with your provider.

Headaches
If you develop new headaches while on birth control pills, contact your provider.

Spotting or breakthrough bleeding
This is vaginal bleeding that occurs during your active pills. This is a common side effect during the first 3 months of birth control pills use and up to 50% of users may experience this. By the third pack of pills, 90% of women are no longer experiencing spotting. Some may notice some mild menstrual cramping with the spotting but this should resolve for most by the third pack of pills as well. Contraceptive effectiveness is present even with spotting, as long as no pills have been missed.

If you are experiencing light bleeding on your active pills that lasts longer than 5 days, or heavier bleeding lasting more than 3 days, contact your provider.

Missed periods or amenorrhea
Sometimes a woman may take all her pills correctly and will not get her period. This can happen for a variety of reasons including stress, illness and travel and, rarely, thyroid or other hormonal issues. A pregnancy test would be advised before starting a new pack of pills. If you have missed pills and don't get your period, or your period is very light, it is particularly important to take a pregnancy test.

If you continue to experience amenorrhea (absence of your period), contact your provider. A change to another birth control pill can help.

Weight gain
Many patients ask about this side effect. Studies have shown that weight changes in young women on birth control pills are no different than women who don't take birth control pills. 3 placebo-controlled randomized clinical studies have demonstrated birth control pills do not cause weight changes. However, some women may react to the hormones with mild fluid retention in some tissue around the breasts and hips.

Mood changes
Some women may notice changes in their emotional status: depressed mood or emotional instability. If you have a history of depression, discuss this with your provider. It is important to monitor your progress carefully when starting birth control pills. If you notice changes in your mood after beginning birth control pills, promptly contact your provider.

Decreased sex drive
While your sex drive is affected by many things, the hormones in birth control pills can be a factor in decreased sex drive. If you are noticing this side effect persistently, let your provider know. A change to another pill or another method of contraception may be considered.

Vaginal discharge
A slight increase in the amount of discharge can occur for some women. Others may notice decreased lubrication with intercourse. Neither change is harmful and extra lubrication can be used as needed to make sex comfortable.

Contact lens use
Rarely, women who wear contacts may notice some visual changes or change in lens tolerance. Consultation with your opthalmologist can help with this.

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Rare but serious side effects:

Blood clots
BCPs can make women slightly more prone to form blood clots. A blood clot can occur in a vein or artery and can have different symptoms depending on where it forms. Clots can occur in the legs, abdomen, heart, lungs, eye, or brain. In the brain, a clot could manifest as a stroke. The risk of these events occurring is very low, but increases in women over 35, in smokers, and in those with high blood pressure, heart disease, diabetes, clotting tendency, or a family history of clotting abnormalities. The warning signs of a blood clot spell out the word ACHES:

  • Abdominal pain
  • Chest pain (also shortness of breath)
  • Headaches (especially those that are new, severe, or associated with persistent dizziness, difficulty speaking, fainting,numbness or weakness in extremities
  • Eye problems (blurred vision or loss of vision)
  • Severe leg pain (and/or redness and swelling in the calf or thigh)

If you develop any of the ACHES side effects or jaundice (a yellowing of the eyes or skin) while on birth control pills, call Health Services right away at 401.863-1330. If you need emergency medical attention, call EMS at 401.863-4111. If you are out of town, contact a local health provider or go to a hospital emergency room.

High blood pressure
Birth control pills can raise your blood pressure. This is why your medical provider will check your blood pressure a few months after you begin taking the birth control pills.

Liver tumors
Birth control pills have been associated with an increased risk of forming benign liver tumors. This is a very rare occurrence, but you should contact your provider if you develop upper abdominal pain while taking birth control pills. Additionally, birth control pills may accelerate the formation of gallbladder stones in women who have a strong family history of gallstone disease.

Breast cancer risk
Many patients ask about how birth control pills affect their future risk of developing breast cancer. The literature suggests that use of the birth control pill has little if any effect on the risk of breast cancer.

Cervical cancer risk
The risk of developing this type of cancer is slightly increased in birth control pills users. Fortunately, routine Pap smear testing is an excellent screening tool.

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Where can I get birth control pills?

In order to prescribe birth control pills, a medical provider will need to see you for a visit to take your medical history and do a brief physical exam. If you are under 21, you do not need to have a pap smear and you may not need a pelvic exam. If your provider determines that you do need a pap or a pelvic exam, let our staff know if this is your first exam. The medical providers are very sensitive to and supportive of women having their first exams. (Click here to learn more about gynecological exams.)

Brown students can call Health Services at 401.863-3953 to schedule an appointment. There is no charge for a visit to Health Services. Charges would only be incurred if you have a lab test, like a pap smear or an STI test, and for your prescription medication.

You can have your prescription for birth control pills filled at the Health Services pharmacy or at a local pharmacy. Our pharmacy is open Monday-Thursday, 8:30am-7:00pm, Friday 8:30-5:00pm and Saturdays and Sundays from 10:00am-4:00pm, when classes are in session. During breaks, the pharmacy is open 8:30am - 5:00pm, Monday - Friday. During the summer, the pharmacy is open 8:00am - 4:00pm, Monday - Friday. Click here to confirm the current pharmacy schedule. You can also call the pharmacy at 401.863-7882 if you can't make it in during those times and they can arrange for a late pick up.

If you run out of pills for any reason, call Health Services at 401.863-3953, and we can help out until your next appointment.

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How much do birth control pills cost?

A one month supply of birth control pills, if you are paying out of pocket, ranges in cost from $15 to $100, with most pills costing between $30 and $40, at the Health Services pharmacy. If you use your insurance, co-pays will vary by carrier. If you have Brown's student health insurance, there is no co-pay for contraceptives.

How do I start using BCPs?

There are a few ways to begin on the pill. Talk to your provider about which approach makes sense for you.

Quick start or same day start
Take the first pill in your pack on the day you get your pills. Use a back up method for at least 7 days. We recommend using condoms. In fact, we recommend using condoms consistently with birth control pills to protect against sexually transmitted infections. Remember that birth control pills offer no protection from acquiring STIs.

First day start
In this approach, you take the first pill on the first day of your next period. No back up contraception is needed when the pills are started on the first day of your menses.

Sunday start
With the Sunday start method, you take your first pill on the first Sunday after your period begins. If you were to start your period on Friday, you take your pill two days later on Sunday. If your period starts on Sunday, you would take the first pill that same day. If you are taking the pill on the first or second day of your period, you would not need to use a back up method.

Be aware that your first and last active pills can be the most important pills in your pack. Being late starting your next pack or forgetting your last active pill will lengthen the time off the active pills. Lengthening this pill-free interval can allow your body to ovulate. Try to plan carefully when you need to start or purchase your next pack. Remember your pills when you go away for weekends or vacations.

To help you remember to take your pill every day, it is useful to link taking your pill with some daily activity like brushing your teeth or eating a certain meal. You can also set a watch or phone alarm to go off as a reminder. Each day, check your pack to make sure you took yesterday's pill.

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Frequently asked questions

What if I am late taking pills or I miss a pill?
What should I do if I don't get my period?
What if I lose a pill?

What if I am vomiting or have diarrhea?
Can I skip a period on purpose?
What happens if I take other medicines, like antibiotics, while I'm on the pill?

What if I have breakthrough bleeding?
Do I need to stop using the pill from time to time?
Does the pill affect my ability to get pregnant later on?

What if I am late taking pills or I miss a pill?

Missing pills or starting the pack late may make your pill less effective. The chance of pregnancy after missing pills depends on when pills are missed and how many pills are missed. A pill is late when you have forgotten to take it at the usual time. A pill has been missed when it is more than 24 hours since the time you should have taken it.

If you miss 1 pill anywhere in your pack, or start the new pack 1 day late, you will still have contraceptive coverage. However, missing 2 or more pills or starting the pack 2 or more days late (more than 48 hours late) may affect the impact the effectiveness significantly. In particular, during the 7-day pill-free break, your ovaries are not getting any effects from the pill. If you make this pill-free break longer by forgetting 2 or more pills, your ovaries might release an egg and there is a real risk of becoming pregnant.

If you have missed one pill, anywhere in the pack:
• take the last pill you missed now even if it means taking two pills in one day
• continue taking the rest of the pack as usual
• no back-up contraception is needed
• take your placebo pill break as normal

If you have missed two or more pills (more than 48 hours late), anywhere in the pack:
• take the last pill you missed now even if it means taking two pills in one day
• leave any earlier missed pills
• continue taking the rest of the pack as usual and use an extra method of contraception for the next seven days
• you may need to start the next pack of pills without a break. If less than seven active pills are left in the pack after the missed pill, finish the pack and begin new one the next day (this means missing out the break). If seven or more active pills are left in the pack after the last missed pill, finish the pack and have the usual placebo break.
• you may need emergency contraception. If you had intercourse without a condom and have missed two or more pills, Brown students can call Health Services at 401.863-1330 to discuss whether you should consider emergency contraception.

What should I do if I don't get my period?
While your period may be much lighter on birth control pills, you will get a period. Sometimes, however, no period occurs for a range of reasons including the low doses of the hormones, stress, or illness. If you've taken your pills regularly, pregnancy is unlikely. However, we do recommend taking a pregnancy test to rule out this possibility before starting your next pack of pills. Health Services performs confidential urine pregnancy tests at no cost for Brown students. If you aren't getting a regular period on birth control pills, we may suggest a different pill.  

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What if I lose a pill?
If a pill is lost, you should replace it from a separate pack of pills. Brown students should call Health Services at 401.863-1330 if this happens. Advice may vary depending on where you are in your pack and what type of pill you are on.

What if I am vomiting or have diarrhea?
If you vomit within two hours of taking your pill, you should consider that pill missed, and take another from a separate pack, as soon as you can keep things down. If you have 3 or more loose bowel movements for 2 days, the effectiveness of the pill may be reduced. We recommend that you abstain from sexual activity or use a condom for the duration of your illness and for 7 days afterwards.

Can I skip a period on purpose?
There may be a week when you would really like to avoid your period because of a special trip or event. You may accomplish this by not taking the placebo week of pills. Instead, throw them out and start your next pack of pills. Your period should hold off until you finish this new pack. This works a bit better with monophasic pills than with triphasic pills. If you'd like to try this method, call your provider to discuss the details.

What happens if I take other medicines, like antibiotics, while I'm on the pill?
There is a lot of conflicting information surrounding this issue. In particular, your prescription insert will list "antibiotics" as decreasing pill effectiveness. However, unless your antibiotic or other medication is listed below, it does not reduce the effectiveness of the pill and does not require that you use a back up method, contrary to the product labeling.

The following medicines WILL DECREASE the effectiveness of the birth control pill: Topamax, Lamictil, Tegretol, Nevirapine, Trileptal, Phenobarbital, Dilantin, Mysoline, Rifampin, St. John's Wort, Provigil, Ethosuximine, Griseofulvin, Troglitazone, and Vigabatrin.

The following medicines will NOT DECREASE the effectiveness of the birth control pill: Ampicillin, Biaxin, Cipro, Doxycycline, Diflucan, Zaratontin, Keppra, Sabril, Zonegram, Lyrica, Klonopin, and Bafitril.

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What if I have breakthrough bleeding?
Spotting or bleeding during the active pills of your pack is termed breakthrough bleeding. It is extremely common during the first three months of pill use. This bleeding can usually be ignored and should resolve by the third pack. If light bleeding persists for more than 5 to 7 days or heavy bleeding persists for more than 2 to 3 days, call your provider. We will sometimes recommend taking two pills a day (one it the morning, one in the evening) until the bleeding stops. The extra pills should be drawn from a separate pack of pills. Usually the extra pills need to be taken for 2 to 3 days. Breakthrough bleeding can also occur if you are late or forgot a pill. If you are experiencing breakthrough bleeding after your 3rd month of pill use for no obvious reason (you've taken your pills perfectly), you should call your provider.

Do I need to stop using the pill from time to time?
There is no evidence you need to take a break from the pill periodically. It's generally not recommended to stop the pill unless you plan to stay off for 3 months or longer. The best time to stop is at the end of your pack. Stopping during a pill cycle will usually be followed by some bleeding; count this as a menstrual period. Remember that you could become pregnant as soon as you stop taking the pills. However, your next normal period may be delayed. If normal menstruation does not return in 8 weeks, see your provider to determine why.

Does the pill affect my ability to get pregnant later on?
There is no evidence that birth control pill usage at any time is related to infertility.

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Links you can use

To learn more about birth control pills, you can visit:

Planned Parenthood

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Disclaimer: Health Education is part of Health Services at Brown University. Health Education maintains this site as a resource for Brown students. This site is not intended to replace consultation with your medical providers. No site can replace real conversation. Health Education offers no endorsement of and assumes no liability for the currency, accuracy, or availability of the information on the sites we link to or the care provided by the resources listed. Health Services staff are available to treat and give medical advice to Brown University students only. If you are not a Brown student, but are in need of medical assistance please call your own health care provider or in case of an emergency, dial 911. Please contact us if you have comments, questions or suggestions.