In the last blog post in this series, we try to answer some of the most frequently asked questions about the contraceptive Pill!

This four-post series aims to empower you with a lot of information about The Pill, so you can safely find the best option for you! Talk to your GP or gynaecologist about the potential benefits and risks of the different options available to you.

What’s the best Pill to start with, if I’ve never taken the Pill before?

To discover the right Pill for you, you may want to start by considering what makes you unique. For example:
– Your age
– Your current menstrual symptoms: are heavy and / or painful periods a problem for you?
– Your medical history (eg. your BMI, if you’ve had breast cancer or a troublesome blood clot in your leg or lungs in the past)
– Your mental health
– Whether or not you smoke cigarettes
– If you’re currently taking any medications or supplements
– Whether you’re troubled by acne and / or excess hair
– If you’re thought to have endometriosis or polycystic ovarian syndrome
– How often you would like to have a so-called ‘progesterone-withdrawal bleed’: every month, or would you prefer to only bleed every three months?

Considering what’s unique about you is one way to help work out which combined Pill is best for you. You’ll need to chat with your GP (or gynaecologist) about: your personal history and characteristics; your tolerance for the (low) risk of unplanned pregnancy; the risk of side-effects; and your personal values and preferences.

Unless there’s a good reason to start with a different Pill, many clinicians start women on a Pill that contains of combination of 30 – 35 micrograms of ethinyloestradiol (as its oestrogen ingredient) and either levonorgestrel or norethisterone (as its progestin ingredient). This hormonal combination is often considered the ‘gold standard’, in relation to its effectiveness, safety profile and affordability; hence, they’re often considered the best first option for women who want to start taking the combined Pill. Hence, a good Pill to start on is often ‘Levlen ED’: it contains 30 micrograms of ethinyloestradiol, plus 150 micrograms of levonorgestrel; it is monophasic (each hormonal tablet is the same); and it is subsidised under the federal government’s pharmaceutical benefits scheme (PBS).

Many clinicians would recommend taking your initial Pill for three months, while keeping a diary of any side-effects of symptoms you notice. Touch base with your GP (or gynaecologist) after three months, and report back any troubling side-effects you’ve noticed. They can then troubleshoot your options, and undertake some ‘trial and error’ until you find a Pill that works well for you!

How much does the Pill cost?

Only the pills containing levonorgestrel and norethisterone as their progestin ingredient are subsidised under the PBS. The out-of-pocket expense for a four-month subsidised supply is approximately $20, compared to up to $120 – 360 for the newer pills, many of which are not listed on the PBS.

How do I start taking The Pill?

The conventional advice is to: wait until your next period, and start taking the relevant ‘sugar’ pill during that next period. Then take one pill a day, at roughly the same time of the day. In such situations, the Pill is effective as soon as you start taking it; there’s no need to use condoms for the first week of taking The Pill.

In contrast, the so-called ‘quick start’ method is as follows:
– Make sure you’re not already pregnant
– Start by taking a hormonal tablet as soon as you pick up The Pill from the pharmacy
– Take one pill a day, at roughly the same time each day
– Use condoms (or don’t have penetrative sex) for the next seven days
– Do a pregnancy test three weeks after the last time you had unprotected penetrative sex (before you started taking The Pill)

Do I have to take The Pill at exactly the same time each day?

Most combined Pills need to be taken at roughly the same time each day, which means within three hours of the regular dosing time each day. So if you normally take your Pill when you brush your teeth at 7am, try to always take your Pill between 7 – 10am.

The progesterone-only pill ‘Slinda’ has a 12 hour dosing window: ie. if you normally take your ‘Slinda’ tablet at 7am every morning, try to take it between 7am – 7pm every day.

What should I do if I forget to take my Pill?

The rules of ‘missed pills’ can be confusing! Pasted below is a flowchart to help guide you:

(Source: https://www.true.org.au/ArticleDocuments/208/TRUE%20Factsheets%202022%20Missed%20the%20Pill.pdf.aspx?embed=Y )

If in doubt:
– Take the missed pill immediately
– Keep taking one pill a day thereafter
– Make an urgent appointment to chat with your GP or gynaecologist
– Use condoms for the next week
– And think about whether or not you need to take the morning after Pill

I’ve been taking continuous hormone tablets (ie. skipping the ‘sugar’ pills). How long can I do this without taking a break?

It is perfectly safe to take hormonal tablets ‘back-to-back’: ie. to skip the ‘sugar’ pills, and take continuous hormonal tablets. This is typically done for up to three months at time, so that you only have a ‘period’ every three months. There is even evidence available to support the safety of continuous use of the contraceptive pill for up to 12 months.

There are many benefits to skipping your ‘sugar’ pills, such as:
– Reduced blood loss, which can help to prevent anaemia
– Reduced symptoms which are associated with the ‘sugar’ pill week, such as: period pain, bloating / fluid retention, headaches, and altered mood
– Even more effective contraception

Many women experience breakthrough bleeding if they try to take three months of continuous hormonal tablets. A good approach here is called the ‘menstrually-signalled’ regimen: you take continuous hormonal tablets back-to-back, until you get four days of vaginal spotting / bleeding. At that stage, it’s time to admit defeat, and have a period. So, after the fourth day of vaginal bleeding, take four days of ‘sugar’ pills: you will then get a full-blown period. Then go back onto the continuous hormonal tablets.

I didn’t have a period while I was taking my sugar pills. Is this a problem?

Approximately 90% of women who take the combined pill will have a bleed every time they take the monthly ‘sugar’ pills.

If you didn’t have a ‘withdrawal bleed’, and think there is a possibility that you could be pregnant: do a urine pregnancy test, urgently! If this is negative, then you can be reassured: the lack of a ‘period’ is due to your Pill appropriately suppressing some of your hormonal pathways, and is not an indication of any health problem or reduced fertility.

How long should I trial a Pill before changing to another one?

If you’re experiencing severe side-effects or complications, stop your Pill immediately and see your GP (or gynaecologist): if necessary, call an ambulance.

If you are only experiencing mild side-effects (eg. mild nausea, mild breast tenderness): try to keep taking that particular Pill brand for at least three months. Most of these common, mild side-effects get better with time.

If your side-effects don’t get better after a few months, your GP may suggest:
– Changing to a slightly different formulation of The Pill
– Trying a progesterone-only Pill
– Trying a different route of administration for your contraception: eg. a Mirena or Copper intrauterine device; a Nuvaring; an Implanon arm implant; or an injection into your tummy every three months (which is called Depot-Provera).

I stopped the Pill a while ago, and my period hasn’t come back yet. Is this normal?

For 98% of women who stop taking the combined Pill, their normal cycle resumes within three months. If you still haven’t had a period within four months of stopping the Pill: go to see your GP, who may request some investigations (eg. blood tests and / or a transvaginal ultrasound) to look into what’s going on.

Possible causes include:
– Pregnancy: when in doubt, do a pregnancy test!
– Polycystic ovarian syndrome
– Early menopause / primary ovarian insufficiency

Just because your period hasn’t returned, it doesn’t necessarily mean that it’s because of the combined Pill itself, you’re not ovulating, or that you can’t get pregnant.

If you’re concerned, see your GP or gynaecologist.

Will my fertility return as soon as I stop taking The Pill?

After you stop taking the Pill, there may be a very slight, temporary decrease in your fertility (but only for a month or two). 97% of women will return to having a normal period within three months of stopping The Pill. The pregnancy rate within one year of stopping The Pill is similar to the general population: approximately 80% of women conceive within one year of stopping The Pill.

Can I take the Pill if I’m breastfeeding?

Whether or not you’re breastfeeding, you can start taking the progesterone-only Pill straight away.
If you’re breastfeeding, you should wait until your baby is at least six weeks old (and breastfeeding is established) before starting the combined Pill. This is because there are some concerns that the combined Pill may reduce breast milk supply if started earlier than that.

If you’re not breastfeeding, the combined Pill can be started when your baby is three weeks old, provided there are no additional risk factors for venous thromboembolic events (blood clots forming in your legs and / or lungs), such as: raised BMI, family history, having had a Caesarean section, and / or smoking. If you have any of these additional risk factors, your GP may suggest that you wait until your baby is at least six weeks old before starting to take the combined Pill, or may suggest that you try a form of contraception that doesn’t contain any oestrogen hormone.

When in doubt, chat with your GP about your options.

Conclusion

The combined Pill is effective contraception, with some great non-contraceptive benefits, but also has both common (and mild) side-effects, in addition to rare (but serious) complications. Given the dizzying array of pills on the market, unwanted side-effects don’t need to be tolerated. Your GP will guide you through the process of finding the right contraceptive option for you: whether a combined Pill, a progesterone-only Pill, an implant, a Nuvaring, or Copper IUD or even having your tubes tied. Look out for blog posts about these topics in future!