Hesperian Health Guides
Hormonal Methods of Family Planning
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A woman controls hormonal methods and they can be used without a man knowing.
Hormonal methods work by preventing the woman’s ovaries from releasing an egg. The hormones also make the mucus at the opening of the womb very thick, which helps stop the sperm from getting inside the womb.
Most birth control pills and some injections contain both estrogen and progestin. These are called ‘combination’ pills or injections. The two hormones work together to give excellent protection against pregnancy. However, some women should not use pills or injections with estrogen for health reasons, or because they are breastfeeding (see Who should not take combined pills).
Progestin-only pills (also called mini-pills), implants, and some injections contain only one hormone—progestin. These methods are safer than combined pills or injections for women who should not use estrogen, or are breastfeeding.
These women should avoid ANY kind of hormonal method:
Some medicines for seizures (“fits”), for tuberculosis (TB), or for HIV make hormonal methods less effective. A woman taking these medicines should use another family planning method or combine it with a second method such as a condom or a diaphragm.
- Women who have breast cancer, or a hard lump in the breast. Hormonal methods do not cause cancer. But if a woman already has breast cancer, these methods can make it worse.
- Women who might be pregnant or whose monthly bleeding is late.
- Women who have abnormal bleeding from the vagina during the 3 months before starting hormonal methods. They should see a health worker to find out if there is a serious problem.
Some hormonal methods are harmful for women with other health problems. Be sure to check each method to see if it is safe for you. If you have any of the health problems mentioned and still wish to use a method, talk to a health worker who has been trained in hormonal methods of family planning.
The pills will not prevent pregnancy immediately. So, during the first 7 days on pills, use condoms or some other backup method to avoid pregnancy.
If you must change to a lower dose pill, use a barrier method of family planning or do not have sex during the first month.
Combined pills (birth control pills with estrogen and progestin)
Birth control pills will protect you from pregnancy as long as you take one pill every day. There are many different brands of combined pills with different types of estrogen and progestin in them and different amounts of each hormone. The most common combined pills are “low-dose” pills with 20, 30, or 35 micrograms (mcg) of estrogen. Low-dose pills and minipills are different—lowdose pills have both estrogen and progestin, while the minipill has only progestin.
Combined pills are usually available at family planning clinics, health posts, pharmacies, and through health workers.
Once you start taking pills, you should try to stick with one brand (and if you can, buy several packets at once). If you must change brands, try to get another with the same hormone names and strength. You will have fewer side effects and better protection.
Who should not take combined pills:
Some women have health problems that make it dangerous for them to use the pill. NEVER take the pill if you have any of the conditions listed above, or if you:
- have liver disease hepatitis, or yellow skin and eyes.
- have ever had signs of a stroke, paralysis, or heart disease.
- have ever had a blood clot in the veins of your legs, or in your lungs or brain. Varicose veins are usually not a problem, unless the veins are red and sore.
If you have any of the following health problems, try to use a method other than combined birth control pills. But if you cannot, it is still better to take the combined pill than to become pregnant.
Try not to take combined pills if you:
- Smoke and are over 35 years old. You have a greater chance of having a stroke or heart attack if you take combined pills
- Have diabetes or epilepsy. If you are taking medicine for seizures (“fits”), you will need to take a stronger (50 micrograms of estrogen) birth control pill. Get medical advice from a health worker or doctor.
If you are bothered by any body changes after starting birth control pills. Talk to a health worker. She might suggest a different pill
- Have high blood pressure (more than 140/90). If you have ever been told you have high blood pressure or think you might have it, have your blood pressure checked by a health worker. If you weigh too much, have frequent headaches, get out of breath easily, feel weak or dizzy often, or feel pain in the left shoulder or chest, you should be tested for high blood pressure.
Common side effects of combined pills:
If your monthly bleeding does not come at the normal time and you have missed some pills, continue to take your pills but see a health worker to find out if you are pregnant.
- Irregular bleeding or spotting (bleeding at other times than your normal monthly bleeding). Combined pills often make your monthly bleeding shorter and lighter. It is also normal to sometimes skip your monthly bleeding. This is the most common side effect of combined birth control pills. To reduce spotting, be extra careful to take the pill at the same time every day. If the spotting continues, talk with a health worker to see if changing doses of progestin or estrogen will help.
If you are given a new medicine while on the pill, ask your health worker if you should use a barrier method or not have sex while taking the medicine. Some antibiotics and other medicines make the pill less effective.
- Nausea, the feeling that you want to throw up, usually goes away after 1 or 2 months. If it bothers you, try taking the pills with food or at another time of day. Some women find that taking the pill just before going to sleep at night helps.
- Headaches. Mild headaches in the first few months are common. A mild pain medicine should help. If the headache is severe or comes with blurred eyesight, this could be a serious warning sign, see below.
Warning signs for problems with combined pills:
STOP taking the pill and see a health worker if you:
- have severe headaches with blurred vision (migraines) that begin after you start taking the pill.
- feel weakness or numbness in your arms or legs.
- feel severe pain in your chest and shortness of breath.
- have severe pain in one leg.
- have severe pain in the abdomen.
If you have any of these problems, pregnancy can also be dangerous, so use another type of family planning such as condoms until you can see a health worker trained in hormonal family planning methods.
How to take combined birth control pills:
|The pill comes in packets of 21 or 28 tablets. If you have a 28-day packet, take one pill every day of the month. As soon as you have finished one packet, begin taking pills from another packet. (The last 7 pills in a 28-day packet are made of sugar. They have no hormones in them. These sugar pills help you to remember to take a pill each day.)|
|28-Day Pill Packet|
|If you have a 21-day packet, take a pill every day for 21 days, then wait 7 days before beginning a new packet. Your monthly bleeding will usually happen during the days you are not taking pills. But begin a new packet even if your monthly bleeding has not come.|
|21-Day Pill Packet|
|With both 21-day and 28-day packets, take the first pill on the first day of your monthly bleeding. This way you will be protected right away. If it is after the first day, you can start taking a pill on any of the first 7 days of your monthly cycle. But you will not be protected right away, so for the first 2 weeks you are taking the pill you should also use another family planning method or not have sex.
Forgetting to take pills:
|= missed pill|
|= take 2 pills|
If you miss pills you could get pregnant.
If you forget 1 or 2 pills, take 1 pill as soon as you remember. Then take the next pill at the regular time. This may mean that you take 2 pills in one day.
If you forget to take 3 pills, 3 days in a row, take 1 pill right away. Then take 1 pill each day at the regular time.
If you are using a 28-day packet of pills, take only the hormone pills and skip the sugar pills, then start taking hormone pills from a new packet. If you are using a 21-day packet, start a new packet as soon as you finish the one you are taking now. Use condoms (or do not have sex) until you have taken a pill for 7 days in a row.
If you forget to take more than 3 pills, stop taking the pills and wait for your next monthly bleeding. Use condoms (or do not have sex) for the rest of your cycle. Then start a new packet.
Late or missed pills may cause some bleeding, like a very light monthly bleeding.
|The minipill is safe|
and effective during
If you forget a pill, use a barrier method (or do not have sex) for 7 days, AND keep taking your pills.
Because this pill contains no estrogen, it is safer for women who should avoid combined pills for health reasons or who have side effects from combined pills.
The minipill is very effective for most breastfeeding mothers who have not had monthly bleeding since giving birth. It is slightly less effective than combined pills for women who are not breastfeeding and for women who are breastfeeding more than 6 months after giving birth. See the different brand names.
The minipill is usually available at family planning clinics, health posts, pharmacies, and through health workers.
Women with any of the conditions listed above and women who are taking medicine for seizures should not take the minipill. The medicine makes the minipill less effective.
Common side effects of the minipill:
- irregular bleeding or spotting. This is the most common side effect. If it becomes a problem, taking ibuprofen may help stop spotting.
- no monthly bleeding. This is fairly common, but if you go more than 45 days without bleeding you may be pregnant. Keep taking your pills until you can see a health worker to find out if you are pregnant.
- occasional headaches.
How to take the minipill:
- If you are not breastfeeding, or if you are breastfeeding and your monthly bleeding has started again, take the first pill on the first day of your monthly bleeding.
- If you are breastfeeding and have not had monthly bleeding, you can take the first pill any day from 6 weeks to 6 months after giving birth. You may not begin bleeding. This is normal. After 6 months with no monthly bleeding, you can take the first pill any day, but also use a barrier method or do not have sex for the first 2 days.
- Take the pill at the same time every day. If you take the pill even a few hours late, or if you forget to take the pill for only one day, you can become pregnant.
- When you finish a packet, start your new packet the next day, even if you have not had any bleeding. Do not skip a day.
What to do if you miss a minipill:
Take it as soon as you remember. Take the next pill at the regular time, even if it means taking 2 pills in one day. Use a barrier method with the pill, or do not have sex for 2 days. You may have bleeding if you take your pill at a later time than usual.
Stopping the minipill:
You can stop taking the pill any time. You can get pregnant the day after you stop, so be sure to use another family planning method right away if you do not want to become pregnant. If you can wait until the end of your cycle before stopping, your monthly bleeding will be more regular.
Implants (Jadelle, Implanon, Norplant)
Implants are small, soft tubes that are placed under the skin on the inside of a woman’s arm. These tubes contain the hormone progestin and work like minipills. They prevent pregnancy for 3 to 5 years, depending on the type of implant.
How to use implants:
A trained health worker makes a small cut in the skin to insert and remove the implants. This is usually done at a clinic or family planning center.
Implants can be used by women who are breastfeeding and others who have problems with estrogen. Women should not use implants if they have any of the conditions described above, if they have heart disease, or if they want to become pregnant in the next few years. If you are taking medicines for seizures, you will need to use a backup method, like a condom or a diaphragm, as well as the implants.
Common side effects of implants:
During the first months, the implants may cause irregular bleeding (in the middle of your monthly cycle) or more days of monthly bleeding. Or you may have no bleeding at all. This does not mean that you are pregnant or that something is wrong. These changes will go away as your body becomes used to having more progestin. If this irregular bleeding causes problems for you, a health worker may have you take low-dose combined birth control pills along with the implants for a few months. You may also have occasional headaches and the same side effects common with progestin-only injections.
Many women want their implants removed early because they do not like the side effects. The most common concern is irregular bleeding.
To stop using implants:
Implants can be removed at any time—though it can be hard to find a health worker who knows how to remove them. After removal, you can get pregnant right away, so use another family planning method if you do not want to become pregnant.
Birth control injections
In this family planning method, a woman is given injections of hormones every 1 to 3 months, usually at a health center or family planning clinic, by someone who knows how. The protection lasts until you need a new injection, and can be used without others knowing.
Progestin-only injections, such as Depo Provera and Noristerat, contain only the hormone progestin. These are especially good for women who should not use estrogen. They are given every 2 to 3 months.
Women should not begin progestin-only injections if they have any of the conditions listed above, if they are unable to get regular injections, or if they want to become pregnant within the next year.
Common side effects of progestin-only injections:
Progestin-only injections almost always cause changes in the monthly bleeding. You may have light bleeding every day or every once in a while. You will probably stop having monthly bleeding by the end of the first year. These changes are normal.
Because of the large doses of progestin given with each injection, women experience more changes in their monthly bleeding during the first few months than with other hormonal methods.
Other common side effects are:
- irregular bleeding or heavy spotting. If this is a problem, a health worker can give 2 cycles of a combined low-dose birth control pill to take along with the injections to stop the spotting. Most irregular bleeding will stop after a few months.
- no monthly bleeding.
- weight gain.
Other injections, such as Cyclofem and Mesigyna, contain both estrogen and progestin. This type of injection is good for women who want to have regular monthly bleeding. Combined injections are given every month, are more expensive than progestin-only injections, and are harder to find.
Women who should not take combined birth control pills or progestin-only injections should not take combined injections either. Do not begin combined injections while breastfeeding until your baby is 6 months old or your monthly bleeding returns, whichever happens first.
Common side effects of combined injections:
Because the injection contains the same hormones as combined birth control pills, the same side effects are common.
How to use birth control injections:
It is best to get your first injection during your monthly bleeding. This way you know that you are not pregnant. You can start the injections anytime if you are breastfeeding and have not started your monthly bleeding. The injection protects you against pregnancy immediately if it is given within 5 days after your monthly bleeding begins. If the injection was given 6 or more days after the beginning of your monthly bleeding, you should use condoms or not have sex for the next 7 days. You must have an injection every 1, 2, or 3 months, depending on the kind of injection:
- Depo Provera: every 3 months
- Noristerat: every 2 months
- Cyclofem and Mesigyna: every month
Try not to be late getting injections. The injection becomes less effective the longer you wait. If you are late, use a barrier method, or do not have sexual intercourse for 7 days after the injection.
To stop using injections:
You can stop having birth control injections any time you want. But after you stop, it can take a year or more to become pregnant and for your monthly bleeding to return to normal. But it also may come back sooner. So if you do not want to become pregnant right away, you must use another family planning method during this time.