7 Side Effects You May Experience On Oral Contraceptives

While hormonal birth control methods are popular, many women are unaware that oral contraceptives can cause many unpleasant and potentially life threatening side effects. In practice, the seven most common side effects discussed with patients and families are depicted. Most of these problems resolve within the first few cycles of pill use, while others need to be addressed by changing the dose, type of oral contraceptive, or by using a non-oral hormonal birth control method. This paper will serve as a clinician guide, patient education tool and aid to families.

Why It Matters

Oral contraceptives are used for two purposes: for contraception or to prevent pregnancy and for non-contraceptive purposes. Some of the non-contraceptive uses for oral contraceptives include regulating menstrual cycles, reducing excessive bleeding, treating acne, and treating symptoms related to other medical conditions such as premenstrual migraines or Polycystic Ovary Syndrome (PCOS). Because so many women are taking oral contraceptives for non-contraceptive reasons, it is essential to have a full discussion with your physician and/or patient about all possible side effects before starting oral contraceptives. If patients are not fully informed about the side effects of oral contraceives, they may become dissatisfied with their contraception and thus, stop taking their pills at unpredictable times putting them at risk for an unintended pregnancy. Also, if patients do not understand how to use oral contraceptives for the treatment of a medical condition, they may discontinue treatment for a condition that will get worse if left untreated.

Spotting, breast changes, and other symptoms that are frequently experienced by women taking hormonal birth control can influence both patient clinician trust and communication. Women and their healthcare providers may perceive these physical and emotional symptoms as indications that something is wrong with hormonal birth control, even as they are experienced by millions of women worldwide. Education about expected side effects can help prepare women for what to expect and alleviate concern that unusual symptoms, which require emergency room visits, indicate something is seriously wrong. Prior education can also enable providers to offer high quality, consistent care to all women regarding what symptoms are expected and what are not.

Breakthrough bleeding and sexual side effects are two very common complaints in patients taking hormonal birth control. Many of these problems require return visits for further evaluation and management. Additionally, complaints such as vaginitis, painful sex, and blood clots (rare though they are) require immediate evaluation and imaging. It is essential that both patient and provider be able to identify when symptoms occur and how to determine if a patient is in grave danger versus just miserable.

Some considerations may differ when planning for long-term use of estrogen compared with shorter term use. While combined and progestin-only pills both have different safety and side effect profiles, and some women may choose to avoid estrogen entirely for personal reasons related to a history of blood clots or migraine with aura, other women wish to use formulations that can provide adequate cycle control. Future research could further elucidate the effects of combined estrogen and progestin-containing pills on mood, sexual function and the microbiome. For now, the best method and its proper use needs to be considered for each woman individually and she should be asked periodically if she is doing well on her current method of contraception.

So what do people who are just starting out want to know about their blog or website? That people will actually read it.

Patients and their physicians would like to have an idea of what to expect and have an understanding of the duration of side effects. In addition, an understanding of potential alternatives should side effects occur. Most of the side effects that cause annoyance can be managed in the first few cycles of chemotherapy and should not have to interfere with a patient’s quality of life. By having a pre-emptive check in before a patient becomes unwell, both patient and physician can plan and have treatment adjusted to avoid severe and distressing symptoms.

Who It Affects

Side effects of oral contraceptives occur in many women but vary in risk and degree. This risk and degree can be affected by a number of factors including the woman’s age and medical history, the specific pill formulation and any concurrent medications. The way a woman’s body reacts to hormones can also play a large role in how certain side effects may occur. As well as physical factors such as vaginal health, factors such as stress, sleep patterns and mental health history can also affect the risk of experiencing certain side effects. While some side effects are reported more frequently with certain brands than others, individual experiences with specific products can vary widely. Health care providers should give adequate information about potential side effects, and be neither dismissive nor reassuring. Women should know what monitoring is proposed or taking place.

For some women, factors other than a history of delivery will preclude the use of combined estrogen-progestin (CEP) contraception. Patients with cardiovascular disease, cerebrovascular disease, stroke, or thrombophlebitis are generally advised to avoid CEPs because of the increased risk of adverse outcomes from estrogen. In addition, smoking, age greater than 35 years, a history of blood clots or carrier status for conditions associated with thrombophilia, uncontrolled hypertension, and/or migraine with aura all increase the risk of adverse outcomes with CEPs and thus shift the risk-benefit ratio in favor of alternative methods of contraception, such as the progestin-only pills (POPs) or nonhormonal methods.

Patients with a history of depression or anxiety may require closer monitoring for changes in mood on hormonal contraception. Not all women on Hormonal contraception will notice changes in mood. Many women will report feeling well on Hormonal contraception. Recording change in mood at baseline and having a mechanism for following up women with increased symptoms of a depressive or anxious illness, particularly those who have experienced hormone induced mood changes in the past.

Your priorities for sexual health may influence some of the side effects you are willing to accept. Most women would opt not to use hormonal methods if it meant occasional spotting rather than decreased lubrication and arousal, dryness, or less ability to experience orgasm. For others, lighter periods and more reliable cycle control outweigh any sticky or dryness side effects. Understanding and weighing these trade-offs will help you decide whether or not to use a method, and how to choose or continue a method. Sexual health care for patients could be improved if clinicians routinely discussed patients’ desire, arousal, lubrication, and comfort. Patients generally do not think to ask these questions unless their health care provider introduces the topic.

Access to reproductive health methods not only affects the choice of method a woman selects; it also affects the impact that method can have for women in underserved populations. Access can be impacted by the availability and feasibility of appointment time, means of transportation, and out-of-pocket costs for the method itself. Method discontinuation due to side effects without same-day alternative method can put women at risk of unintended pregnancy. As a result, there is a need for systems that support timely follow-up and for affordable switching as well as longer prescription supplies.

What Changes

Providers should inform all patients and clients about expected and unexpected effects of hormonal contraception before they begin use of the method. Many of these side effects are transient, while others may require evaluation. It is crucial that patients and clients understand what potential side effects may occur. Many symptoms are expected in the first few months of hormonal contraceptive use. Some of these symptoms subside in a few months. Other expected or unexpected side effects may be worrisome, but most symptoms do not warrant method change. Absolutely no side effect warrants patient nonuse without a back-up method.

1. Make the method personal to you: If you are experiencing side effects, switch to a different form of the medication, decrease or increase the dose of hormone, or switch to a non-oral hormone delivery method if appropriate. Consider decreasing the dose of estrogen; changing from one form of progestin to another; changing the number of placebo pills; or going to a continuous form of estrogen with or without progestin. If a woman is able and willing, she can maintain her hormone levels on an IUD, implant, ring or patch. Most side effects can be easily remedied with a change in method. Women need to know that a change in method is a normal part of the process of hormone trials and treatments, not a failure.

Screen for risk of thrombosis and consider the effect of other medication that patient is on prescribed or non-prescribed before issuing combined oral contraception. Consider use of alternative progestogen only method for specific purposes. Consider focused safety assessment of combined pill use taking into account blood pressure, history of migraine, current smoker or ex-smoker, postpartum, history of conditions that increase risk of clotting or thromboembolism, family history of thromboembolic disease. Consider impact of prescribed or Over The Counter (OTC)/Recreational medication on effectiveness of method or risk of side effects.

Support access and continuity: make follow-up and alternative products affordable, timely, and accessible. Examples of policies that support continuation of care include: 1) coverage of no-cost switch (e.g. from oral to parenteral) for telehealth counseling, pharmacist supported refills, etc; and 2) multiple month supply (MMS) policies that help prevent missed doses and discontinuation due to lack of access to needed products.

Why These Seven Side Effects Are Emphasized

Every woman using birth control experiences different problems. In this 7-part series we will cover the most common (and worst) problems women deal with on birth control. We will review the frequent side effects of yeast infections, mood swings, low libido and other common problems. We will also discuss the less frequent and potentially life-threatening problems of blood clots experienced by women on estrogen-based birth control. I will also explain the typical symptoms, atypical symptoms and what to do in each case.

How To Think About Each Problem

1) Yeast infections

Causes of Yeats infections can be numerous. Many women notice a change in their propensity to develop yeast infections when they start taking oral contraceptives. Hormonal changes associated with OCs can alter the chemistry of the vagina, making it more susceptible to infection. Additional risk factors for developing a yeast infection include the use of antibiotics, uncontrolled high blood sugar, and the use of substances that can irritate the skin and vagina, such as fragranced soaps, bubble bath, etc.

• Identifying the causative factors of symptoms. Many common symptoms attributed to a yeast infection will resolve with antifungal treatment. However, symptoms that occur frequently may not be caused by yeast. It is important to determine if the symptoms are actually caused by yeast and not by another infection, such as bacterial vaginosis, contact dermatitis, or a mixed infection. • Identify factors that may contribute to recurrence of symptoms, such as: wearing tight, nonbreathable clothing and pajamas; douching; using soaps, bath products, and other cleansers containing fragrances and/or colors; and poorly controlled diabetes.

When to consider a method change. Relentless infections early after a switch to another pill or despite optimal treatment and correct and consistent use of pre-emptive measures warrants discussion of form change or alternative contraceptive methods.

2) Vaginal dryness

Vaginal dryness is an unptempting condition that can cause some degree of discomfort or pain. It is further exacerbated by taking oral contraceptives (O.C.), since some of these formulas decrease free androgen levels (as with FABG’s Tri-Sophistica or Tri-Balance formulas) or don’t give the vaginal tissues sufficient estrogenic stimulation (as with FABG’s Tri-Levetta formulas).

Management of first-line symptoms such as vaginal discomfort or dryness is often straightforward and very effective. In addition to using a patient-friendly explanation to recommend regular use of a vaginal moisturizer and lubricant at time of sexual activity, the patient should be advised to discontinue use of irritating soaps, antiseptics, or douche preparations and use fragrance-free cleansers instead.

Dryness not fully understood. Other factors that may contribute to persistent, severe or unpleasant dryness: breastfeeding, antihistamines and/or antidepressants. Consider possibility of vulvar skin disease and/or pelvic floor disorder. If symptoms clearly linked to a particular pill, then switching to another form or going non-oral may be helpful if symptoms do not resolve.

3) Decreased libido

In many women using hormonal contraception, there is a change observed in their libido. When exploring this aspect of women’s sexuality, it is often helpful to consider how other factors might be influencing their sex drive as well, including relationship factors, energy, stress, mood, pain and vaginal comfort. Therefore, the change in libido is rarely due to one single factor and can be more complex than attributing it solely to the pill.

After determining the time frame in which the decrease in sexual desire occurs, it may be helpful to assess if other more distressing symptoms may be contributing to her decrease in sexual desire. Are her vaginas dry or painful during sexual contact? Is he or she feeling depressed, anxious, irritated, blue, or experiencing other negative emotions? These symptoms can decrease sexual desire. It may take a few months for the body to adjust to the pill, so it is worth waiting a few months to see if symptoms subside. If the decrease in sexual desire persists and is clearly related to the pill, then there are other pill options or alternative methods of birth control that can be very helpful.

Ask patients on the pill about sexual function. Have you noticed any changes in desire, arousal, lubrication, or comfort since starting the pill? Lead-in is straightforward to elicit a straightforward answer.

4) Breakthrough bleeding or spotting

Bleeding or spotting in the first few months of pill use is fairly common. It does not necessarily mean the pill is not working, but rather that the body is going through some adjustments. Breakthrough bleeding can occur if all prescribed pills are not taken exactly on time, and it is more common with certain combinations and uses of oral contraceptives. Breakthrough bleeding can also occur with progestin-only preparations (mini-pill), and is more common with low-estrogen 28-day Seasonale than Seasonique. Cigarette smoking is also known to increase the risk of bleeding irregularities.

For initial assessment and adherence evaluation. Assess for: missed or late doses; vomiting and/or diarrhoea; potential interactions with other medications. If bleeding is very persistent or very heavy, accompanied by pelvic pain or abnormal vaginal discharge, consider that patient may be at risk of pregnancy. Refer for pregnancy test if appropriate. Consider referral for STI screen if patient history suggests risk.

Spotting can occur for a number of reasons, but by being consistent and making some slight adjustments, the incidence of spotting can be lessened. Taking the same dose of your same hormone pill at the same time every day can make all the difference. Even changing the dose, form, or method of the birth control pill, or having a planned bleed to get onto a continuous dosing method of hormone-based birth control can make all the difference. However, if these measures don’t solve the problem of the spotting, it is time to consider alternative methods of birth control.

5) Breast tenderness

Breast tenderness is often caused by hormonal changes that occur in the body ahead of menstruation and is usually nothing to worry about, fading away in the couple of weeks before the next cycle. Some women may experience swelling, some soreness, some tenderness. Others may be troubled by a variety of premenstrual symptoms.

Common complaints of the skin of the breast, swelling and soreness are usually easily managed with a good fitting bra, simple pain relief medication and reassurance. However, persistent severe soreness, change in symptoms once bra fit has been altered, new lumps, nipple discharge or changes to the skin or areola need medical evaluation.

For some women, a change in formulation can make all the difference. For other women, a decrease in the amount of hormones or a change in the form of hormone replacement may alleviates the symptoms.

6) Mood changes

Mood changes can occur in some patients but are very variable. Some women feel they are not affected at all and even improve on hormone replacement therapy because it helps to stabilise their menstrual cycles or reduces symptoms that were particularly distressing. Others can become more irritable or anxious or develop low mood, particularly if they are very sensitive and have a history of mood disorders.

Take a cautious and patient-orientated approach. Record the patient’s baseline mood; use brief screening tools if needed and record follow-up moods on subsequent packs. If mood symptoms worsen and affect function, advise an alternative method of contraception.

When to seek help When any of these symptoms occur think that someone else might need to come right away. Urgent evaluation is appropriate for any suicidal thoughts, severe depression, any panic-like symptoms, or inability to function that is likely related to a medication.

7) Blood clots

Patients taking estrogen-containing medications should be advised of the rare but serious risk of blood clots. Combined estrogen-progestin oral contraceptives increase the risk of venous thromboembolism (VTE) more than non-use, whereas progestin-only oral contraceptives do not increase the risk of blood clots.

The safest way to counsel women about the birth control methods that may be associated with an increased risk of thrombosis is to first make certain that the woman has been counselled as to the most appropriate method of contraception for her situation. In addition, the patient must be informed as to whether her medical situation would place her at increased risk of thrombosis. The following are some of the known risk factors for thrombosis: • Current or recent (within the past year) use of oral estrogens or combination hormonal contraceptives; • Surgery or trauma that may require postoperative thromboprophylaxis; • Cancer and its treatment, especially cancers that are associated with a hypercoagulable state; • Immobility resulting from illness, injury, or surgery; • Family history of thrombosis; • History of vascular disease, such as myocardial infarction or stroke; • History of thromboembolic disease; • Long-term immobilization; • Pregnancy; • Presence of medical conditions that are associated with hypercoagulability; • Use of dextran or certain blood transfusions. Patients with these risk factors would ideally choose from the progestin-only or nonhormonal methods.

Patients should be aware of potential warning signs and know what to do if they occur. One-sided leg swelling or pain, sudden shortness of breath, chest pain, coughing of blood, or any other sudden neurologic symptoms should be brought to the attention of your physician as soon as possible.

Clinical Decision-Making And Practical Steps

First and foremost the patient and provider need to share in decision making and develop a plan for follow up. This would ideally include questions about prior hormonal preparation, history of thrombophilia, prior migraine frequency and severity, intent for future breastfeeding and whether or not the patient is in the postpartum period. Additionally, it would be helpful to understand if the patient has a history of mental health disorders as well as her current medication regimen. The patient needs to have a clear understanding of what to expect from symptoms over the first few cycles of hormonal preparation, and then have a clear means of contacting the provider for any symptoms that occur outside of that timeframe.

A practical “3-part plan” supports adherence and safety.

• What is common and often temporary: spotting, mild breast tenderness, mild nausea, minor mood shifts.
• What can be managed at home: lubricants for dryness, moisturizers, supportive bras, taking pills consistently.
• What needs evaluation: heavy or persistent bleeding, recurrent infections, severe mood symptoms, or clot warning signs.

Switching methods is part of good care. If side effects are getting in the way of life, discuss a switch to another combined pill, to a progestin-only pill (Depo, implant), or to another non-oral method (IUD). For patients who have difficulty taking a daily pill, long-acting reversible contraception (LARC) can alleviate this burden and often has a different side-effect profile.

System And Policy Implications

Outcomes are improved when individuals and couples can start, continue to use, and switch to methods that are most suitable for them freely. It is essential that low-cost method change be covered in any payment structure. Follow-up by telehealth and access to local pharmacies to address side effects promptly can also help to prevent sudden method discontinuation.

Having education and standardized counseling tools for side effects and treatment switching is crucial to ensuring consistent reproductive health education to patients with HIV/AIDS. Normalizing discussion of these side effects and issues to front-line clinicians is also important in order to ensure that patients are not blamed for non-adherence.

What Comes Next

Future research directions for reproductive health research could include: 1) Evaluating the impact of different forms of hormonal contraception on mood and sexual function, and 2) examining the effects of hormonal birth control on the vaginal microbiome. Clinically, recommendations for hormonal birth control use are currently more individualized based on medical risk, life stage, and patient preferences.

Clinicians and health care systems must emphasize early counseling, regular follow up, and access to alternative methods for women initiating hormonal contraception. Most side effects can be managed safely and patients should know that they can speak up and explore alternative approaches without compromising efficacy.

References:

https://pmc.ncbi.nlm.nih.gov/articles/PMC11491692/ https://www.ncbi.nlm.nih.gov/books/NBK430882/ https://medlineplus.gov/druginfo/meds/a601050.html