Which Oral Contraceptive Pill is Best for Me?
Frederick R. Jelovsek MD, MS
"I am 25 years old. I haven't had a period in about 6 months but I don't want to get pregnant now. I'm overweight and can't lose any, I am always tired, have acne that I can't clear up, and I have excess body hair. I have been put on birth control pills but they haven't helped. What would be the best brand of pills for me to be on for my problem? Also, my pills cost $30.00 a month. Are there any sources for free pills?" Anonymous
Be sure to give the pills you are currently taking a fair trial of at least 2-3 months. If your pills are switched, also give them 2-3 months trial because it often takes 2 months just for your body to adjust to the estrogen and progestin in an oral contraceptive. Also when we say a pill has certain characteristics because of its estrogen dose and its progestin dose and potency or androgenicity (male hormone effect), every woman responds differently to those components and sometimes the general principles just do not apply.
With your history of infrequent menstruation, you may have a condition of either polycystic ovarian syndrome (PCOS) or a stress-like hypothalamic anovulation. In either case, birth control pills are a good treatment for those conditions if you do not want to get pregnant at present. In the case of hypothalamic anovulation there are often low or low normal estrogen levels and the pill will increase those levels to mid-normal range. In the case of PCOS, the extra estrogens from the pill will result in an increased binding (inactivation) of any excess testosterone from the polycystic ovaries as well as suppress some of the testosterone production from them. With PCOS you would avoid a pill with increased androgenic (testosterone-like) activity and do better with one with higher estrogen levels as far as combatting the excess body hair you indicate is present now.
Many experts believe there are no consistent side effect differences between different formulations of birth control pills because all pills have been reduced in dose so much from when older data on higher dose pills was examined. Others agree that those unique side effects have been reduced but they are still manifest in some women. In my experience some women still have side effects according to the different oral contraceptive components and their doses in a given pill formulation.
How do the doses of pill components vary by brand of pill?
Birth control pills now have only one (synthetic) estrogen type, ethinyl estradiol. Therefore the estrogen potency of a given pill is directly related to the number of micrograms of ethinyl estradiol with one exception. Sometimes the specific progestin also has some estrogen activity. For the most part, the estrogen potency of the progestins is small in comparison with ethinyl estradiol so it is not added in to potency tables.
Estrogen and Progestin Hormone Doses in Combined Birth Control Pills
|Estrogen level |
|Pill Brand Name||Progestin||Dose (mg)|
|Loestrin 1/20® Fe||norethindrone acetate||1.00|
|Estrostep® Fe||norethindrone acetate||1.0/1.0/1.0|
|Loestrin® 1.5/30||norethindrone acetate||1.50|
|Demulen® 1/35||ethynodiol diacetate||1.00|
|Zovia® 1/35E||ethynodiol diacetate||1.00|
|50 mcgm||Necon® 1/50||norethindrone||1.00|
|Demulen® 1/50||ethynodiol diacetate||1.00|
|Zovia® 1/50E||ethynodiol diacetate||1.00|
Which pills have higher progestin side effects or cause more acne and hair growth?
Each progestin has a different potency, milligram per milligram, in terms of progesterone effect to stop menstrual bleeding or androgen effect to stimulate acne and hair growth. However you must remember that a higher potency progestin may be used in a much smaller milligram dose and thus be equivalent to a larger milligram dose of a less potent progestin. For example, desogestrel is a very potent and androgenic progestin but its usual oral contraceptive dose is 0.15 mg instead of 1.00 mg for norethindrone. Its progestin potency compared to norethindrone would be 0.15 X 9.0 = 1.35 times. For androgenicity, it would be 0.15 X 3.4 = .51 or half as androgenic as a pill containing 1 mg of norethindrone.
Progestin Potency of Different Oral Contraceptive Progestins*
|Progestin||Progestational Activity |
(relative to 1 mg of norethindrone)
(relative to 1 mg of norethindrone)
|norethindrone 1 mg||1.0||1.0|
|norethrindrone acetate 1 mg||1.2||1.6|
|ethynodiol diacetate 1 mg||1.4||0.6|
|levonorgestrel 1 mg||5.3||8.3|
|dl-norgestrel 1 mg||2.6||4.2|
|norgestimate 1 mg||1.3||1.9|
|norelgestromin 1 mg**||1.3||1.9|
|desogestrel 1 mg||9.0||3.4|
|drospirenone 1 mg||1.5||0.0|
* - From Table 2 in Dickey RP: Individualizing oral contraceptive therapy. OBG Management Supplement October 2000, p 5.
** - Not yet tested but it is the major active metabolite of norgestimate
The pills that are likely to cause worse acne and hair growth side effects are those pills high in androgenicity and low in estrogen content. Such pills might include:
- Loestrin® 1.5/30
- Loestrin® 1/20 Fe
- Estrostep® Fe
- Norlestrin® 1/50
Keep in mind that MOST women on these above pills DO NOT have acne problems, just those that have a tendency toward androgenicity.
What pills would be better for...?
In order to classify an oral contraceptive as an estrogen dominant, progestin dominant or androgenic pill, you must multiply the actual dose of the components times the relative potency of that component. Keep in mind that these are relative classification and do not always hold from one woman to another. For different oral contraceptive side effects, you might consider switching to the pills indicated in the table below to minimize those side effects.
Current Pill Problems and Choice of Pill to Switch To
|Side Effect/Problem||Principal||Pill Suggestions|
|Acne||higher estrogen, lower androgen potency||Yasmin®, Demulen® 1/50, Othro-Tri Cyclen®, Ortho-Cyclen®, Yasmin®, Brevicon®, Modicon®, Necon®, Ortho Evra®, Mircette®|
|Break-through bleeding||higher estrogen, higher progestin potency, lower androgen potency||Yasmin®, Demulen® 1/50, Zovia® 1/50E, Ovcon® 50, Desogen®, Ortho-Cept®, Estrostep® Fe, Loestrin® 1/20|
|Absent or too light menstrual flow||higher estrogen, lower progestin potency||Ortho-Cyclen®, Ovcon® 35, Brevicon®, Modicon®, Necon® 1/50, Norinyl® 1/50, Ortho-Novum® 1/50, Necon® 1/35, Norinyl® 1/35, Ortho-Novum® 1/35,|
|Depression||lower progestin potency||Ortho Evra®, Ovcon® 35, Ortho-TriCyclen®, Othro-Cyclen®, Brevicon®, Modicon®, Necon® 1/35, Alesse®, Levlite®, Tri-Levlen®, Triphasil®, Trivora®|
|Moodiness or irritability||lower progestin potency||Ortho Evra®, Ovcon® 35, Ortho Tri-Cyclen®, Othro-Cyclen®, Brevicon®, Modicon®, Necon® 1/35, Alesse®, Levlite®, Tri-Levlen®, Triphasil®, Trivora®|
|Headaches (not menstrual migraines)||lower estrogen, lower progestin potency||Ortho Evra®, Alesse®, Levlite®,|
|Breast soreness||lower estrogen, lower progestin potency||Yasmin®*, Ortho Evra®, Alesse®, Levlite®, Loestrin® 1/20 Fe, any lower estrogen pill than currently on|
|Weight gain||lower estrogen, lower progestin potency||Yasmin®*, Ortho Evra®, Alesse®, Levlite®, Loestrin® 1/20 Fe, any lower estrogen pill than currently on|
|Severe menstrual cramps||higher progestin potency||Yasmin®, Desogen®, Ortho-Cept®, Mircette®, Loestrin® 1.5/30, Demulen® 1/35, Zovia® 1/35E, Demulen® 1/50, Zovia® 1/50E|
|Endometriosis or endometriosis prevention||lower estrogen, higher progestin potency, higher androgen potency||Loestrin® 1.5/30, Loestrin® 1/20 Fe, LoOvral®, Levlen®, Levora®, Nordette®, Demulen® 1/35, Zovia® 1/35,
(used either continuously with zero days of placebo pills or with only 4 days of placebo pills for prevention)
* - The progestin has anti-water retention properties
Where can I get free or discounted birth control pills?
Planned Parenthood organizations and your local county Public Health Department often provide birth control pills on an ability to pay discounted scale. If you qualify, they may even be free. Look up in the yellow pages phone directory for the Planned Parenthood or Public Health Department for the county you live in. Give them a call and ask about the costs of pills. If you are in college either full or part time, you may also be qualified to use the student health facility and often they provide oral contraceptives at cost or a discount.
When your doctor prescribes a given oral contraceptive, most of the time they indicate it can be filled with a generic equivalent. If not, ask the doctor to please do that or ask the nurse to have a prescription rewritten for a generic equivalent. There are sources on the Internet that will except mailed-in prescriptions and the cost of a generic equivalent is often in the $12-15 range.