Even more than 50 years after the first contraceptives were approved, the contraceptive pill is still the most commonly used contraceptive in Western industrial nations.
In Europe, about four out of ten women between the ages of 15 and 45 use one or the other form of the pill. This contraceptive is used particularly frequently by young women under the age of 30.
The contraceptive pill is one of the hormonal contraceptives. The contraceptive pill works by preventing the egg from maturing every month and thus ovulation. Whereas pills used to be highly dosed, today's modern preparations contain the hormones in the lowest still effective dosage. The lower dosage has also significantly reduced the side effects of the pill.
The pill is a very effective method of contraception. If you wish to have children later, the pill can be discontinued without any problems. After discontinuation, the pill has no effect on fertility.
What all pill preparations have in common is that they contain sex hormones - albeit in different compositions and dosages. A basic distinction is made between the following types of pill:
Combination preparations (the "classic" contraceptive pill)
The "classic" pill contains the hormones estrogen and progestin. An estrogen dosage of less than 0.05 milligrams per tablet is also referred to as a micro pill (not to be confused with the minipill!).
Since today, however, hardly any preparations with higher dosages are prescribed - the majority of preparations contain between 0.02 and 0.03 milligrams - the term micro pill no longer has any great significance.
For the progestin components, various active ingredients are used (e.g. levornogestrel, desogestrel, drospirenone), which differ in their potency. Therefore they are contained in the individual preparations partly in very different dosages. But the progestins also differ in the possible side effects, which is why it makes sense to switch to another preparation in the event of any side effects.
Other hormonal contraceptives that contain a combination of estrogen and progestin are the contraceptive patch and the vaginal ring.
An overview of the mechanisms of action of the contraceptive pill:
The supply of estrogen and progestin influences the hormonal regulatory circuits between the brain and ovaries. Normally, one ovum matures in the ovary per menstrual cycle, resulting in ovulation and thus fertility. Hormonal contraception prevents this (ovulation inhibition).
At the same time, the lining of the uterus is built up less strongly during the cycle, which is why menstruation in women taking pills is usually weaker and shorter than natural menstruation.
The pill is therefore particularly suitable for women who suffer from menstrual pain. Good cycle control is mainly due to the effect of estrogen.
The progestogen contained in the pill also prevents fertilisation by making the mucus plug at the entrance to the uterus more viscous. This impairs the function and mobility of sperm and makes it difficult or impossible for them to penetrate the uterus and fallopian tubes.
The pill is an effective method of contraception with a Practical Pearl Index of about 8. The most frequent reasons for failure of the pill are application errors, in particular forgetting to take it, diarrhoea or no prescription. If taken correctly, only about 0.3 of every 100 women become pregnant within one year (Theoretical Pearl Index of 0.3).
The Pearl Index is the usual form for assessing the effectiveness of contraceptive methods. It indicates how many out of 100 women who use the contraceptive for a year become unintentionally pregnant.
Often only the Theoretical Pearl Index is given because it is lower and looks better. However, this index is not very meaningful, because sexuality takes place in real life and there are also mistakes in its application.
Despite the use of the pill, pregnancies can occur, especially if mistakes have been made in taking the pill or if certain additional medications have been taken.
On the one hand it can happen that the woman forgets to take a pill daily, e.g. because of great stress or she has not obtained a prescription and the last pack is used up.
And when taking medication, always pay attention to possible interactions. In particular, antibiotics or drugs that influence the liver metabolism (e.g. antiepileptics) can limit the effectiveness of hormonal contraceptives. Additional contraceptive measures should be taken during this time.
Stomach or intestinal problems can also reduce the effectiveness of the pill. If vomiting occurs within four hours of taking the pill, it is likely that the hormones have not yet been fully absorbed. Efficacy cannot be guaranteed. Even in diarrhoeal diseases, which are often accompanied by a change in the intestinal flora, the uptake of hormones from the intestine can be reduced and contraceptive protection therefore reduced.
Remember: the pill is an effective method of contraception, but it does not protect against sexually transmitted diseases.
The pill is basically suitable for almost all women who are fertile but currently do not want to have a child - from young women to menopausal women. However, for all forms of hormonal contraception, a careful physical and gynaecological examination and anamnesis must be carried out before the prescription. The specialist can then assess whether a pill is suitable in the individual case and which preparation may be preferred.
Due to the influence on the cycle, some pill preparations are particularly suitable for women with the same condition:
The formation of cysts in the ovaries or the clinical picture of endometriosis can also often be positively influenced.
The progestins contained in the pills also have a regulatory influence on the male sex hormones (androgens). Disturbances in the androgen balance can lead to oily or impure skin, acne or hair loss. In these cases, the pill can improve the symptoms and is often used therapeutically.
The minipill is the pill of choice for women who cannot tolerate oestrogen.
Combination pills should not be taken while breast-feeding, the minipill is also suitable for breastfeeding women.
The pill has been researched for over 50 years and is very well tolerated by most women. However, like all medicines, it can also lead to undesirable side effects. These include:
One of the most feared side effects is thrombosis or stroke. The risk for these diseases is very low, but can increase with the use of the pill, especially if there are other risk factors for cardiovascular diseases such as smoking, obesity, bed-rest, long journeys by plane, atherosclerosis or fat metabolism disorders.
The combined pill, ring or patch is therefore generally not suitable for women with an increased risk of thrombosis, i.e. in cases of blood clotting disorders, thromboses that have already occurred or diabetes. The pill may also not be used for certain tumour diseases (e.g. breast cancer). Heavy smokers have an increased risk of thrombosis due to smoking, which is further increased by the pill.
Careful clarification of the individual risk profile before the first prescription is just as important as regular follow-up checks.
The costs of contraception are not covered by health insurance in Europe, the individual preparations cost around 10 to 15 euros per month. Some preparations are also available in bulk packs (e.g. for three or six months), which are usually cheaper.
In most other Western European countries, the cost of contraception is taken for granted, at least for young people and women with low incomes.
Written by Mark Riegel, MD
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