How to Choose the Least Worst Birth Control Pill

Illustration: Luyi Wang

WWhen I first went on the birth control pill, I was a passive observer in the process: My doctor gave me a prescription, I filled it, and I didn’t ask any questions. I knew almost nothing about the medication, what was in it, or why it was being chosen for me. It’s not like I was being irresponsible or my doctor was being secretive; it’s more like — that’s just the way it went. You got the birth control pill you got, often without really understanding why. But there’s reason to believe this might be changing.

In an age of increased interest in health and wellness, women are demanding more transparency when it comes to the things they put in their bodies. We want to know what’s in our food—think of that viral image of “what Nutella is actually made of.” Earlier this year, the NPD Group reported that more consumers are seeking out beauty products that are free from ingredients like sulfates, phthalates, and gluten. And just this month, New York became the first state to require menstrual-product manufacturers to disclose the ingredients in pads and tampons.

That’s just the way it went: You got the pill you got, often without really understanding why. But there’s reason to believe this might be changing.

But what about birth control pills? There are close to 100 different formulations of the pill, which can make the question itself feel overwhelming. It doesn’t have to be. Familiarizing yourself with some of the basics of birth control ingredients and their known side effects can make you a participant in — rather than a recipient of — your birth control strategy. This will enable you to work together with your doctor to find the pill that will allow you to feel most at home in your own body.

Here are the questions to ask your doctor so you’ll understand more about the birth control you’re taking and how it makes you feel.

What’s in it?

The first step is to find out what hormones are in your pill. The majority of birth control pills out there are combination pills containing synthetic estrogen and synthetic progesterone (called progestin). Most pills contain the same type of synthetic estrogen, but there are about 10 different types of progestins in use. Each of these is categorized by generation — in other words, later-generation progestins are more recent additions to the marketplace. (See the list at the end of this article to learn more about each generation of progestin, as well as the names of popular progestins within each category.)

Make note of the type of progestin that’s in the pill you’re being prescribed; you can find this out by asking your doctor or looking up your prescription online. Most of the issues women have with their birth control pills are the result of their body not agreeing with a particular progestin, so this is where you should start.

How is it administered?

The next thing you need to make note of is how the hormones are administered. This is an easy one: Is it a pill, patch, ring, shot, or IUD? Although all hormones that you put into your body end up in the same place—and that “place” is everywhere your blood travels—the method of delivery seems to matter when it comes to side effects.

For example, research on the relationship between pill use and the risk of depression finds different risks for those using oral products (that is, the pill) compared to those using non-oral products (such as a patch or IUD). This suggests that you can’t assume a progestin administered to your body one way will behave the same way when it’s administered using some other means.

How does it make you feel?

This is the piece that takes the most work, but it’s where you’ll get the biggest payoff. Become an expert in you — how you feel when you’re on the pill you’re on (and off it, if you haven’t started yet). A growing body of research in psychology and neuroscience is finding that the brain is one of the organ systems most affected by the pill. These studies are discovering that the pill influences psychological processes involved in sexual attraction and partner preferences, the desire for sex, the nature of the stress response, learning and memory, mood, suicide risk, and much more.

The pill changes the version of yourself that your brain creates. This means that as you’re working with your doctor to personalize your birth control strategy, you’ll want to keep track of how you’re feeling both psychologically and physically to troubleshoot your options.

Take a couple cycles to keep track of how you feel. Be systematic about it: Write it down in a journal or using a journaling app on your phone. Note how you’re feeling in terms of mood, appetite, energy, sleep, libido, and any other life dimension that you think might be relevant to your decision.

Here is a list of questions to get you started:

  • Do I feel like myself?
  • Have my behaviors changed?
  • Has my mood changed?
  • Have my relationships (both sexual and nonsexual) changed?
  • Has my performance at school or work changed?
  • Have my motivations changed since going on the pill? Am I more or less motivated to do things that I used to like to do before going on it?
  • How do I feel about all of this? Sometimes these changes are for the better; sometimes for the worse.

Even if you’re already on the pill and don’t have a baseline, it’s not too late. Simply make note of how you’re doing in each of these major categories, and take that as a starting point. You should feel happy and vibrant on more days than not when things are going well in your life. If you feel good about your pill, you’re all set. Be glad that it was so easy for you.

If not, don’t despair. Here’s what to do next.

Now, to strategize

If you’re not feeling your best on your prescribed form of birth control, know that you have options. First, investigate the type (generation) of progestin. (Again, for more on that, see the list below.) If you’re on a pill that uses a third-generation progestin, for example, and you don’t like how you’re feeling on it, ask your doctor about trying one that uses a second- or fourth-generation progestin and see if you prefer how it makes you feel. Give it a couple cycles, and keep up with the journaling. Once you find a progestin that your body responds to, you can work with your doctor to try to minimize some of the more minor annoyances (like bleeding between periods) by playing around with different dosages of progestin and estrogen.

Finding the right pill can take some time and requires a little patience. The way women’s bodies respond to different formulations of hormones can vary, and science can’t yet make accurate predictions about who is going to respond which way to what. Still, taking the steps necessary to understand what’s in your birth control pills can be well worth the trouble if it means you find one that you like.

Generations of progestins

First and second generation

Derived from testosterone. Known to increase a person’s risk of experiencing testosterone-related side effects, such as decreasing “good” cholesterol, increasing weight gain, acne, and causing hair growth in places you probably don’t want hair. (These effects are usually offset by the estrogen in these pills, but some women still experience these types of side effects.)

Some names: Medroxyprogesterone (first), norethindrone (first), levonorgestrel (second)
Some products containing this: Ortho-Novum (first), Depo Provera (aka “the shot”) (first), Mirena IUD (second), Seasonale (second)

Third generation

Derived from testosterone; however, the testosterone molecules in this generation have been manipulated to decrease the typical side effects (weight gain, acne, hairiness). These come with a higher risk of blood clots than generations one and two.

Some names: Esogestrel, etonogestrel, norgestimate
Some products containing this: Ortho Tri-Cyclen, Nuva Ring

Fourth generation (dienogest)

Derived from testosterone. Unlike generations one through three, this one actually blocks testosterone receptors, which means the testosterone can’t be “read” by the cells in your body.

That means fewer breakouts and less weight gain. This generation of pill works well for those who have problems with testosterone-related side effects and bleeding between periods.

Be aware, however, that testosterone plays a role in women’s sexual responsiveness, so watch for changes there.

Name: Dienogest
Some products containing this: Natazia, Qlaira

Fourth generation (drospirenone)

This is the lone progestin that is not made from testosterone; instead, it’s derived from a diuretic called spironolactone. Of all the progestins, this one has the most potent anti-testosterone effects out there. It often promotes clearer skin and can promote initial weight loss, because it can decrease water retention caused by estrogen.

Again, because testosterone plays a role in women’s sexual responsiveness, keep an eye on whether that changes.

Name: Drospirenone
Some products containing this: Yaz, Yasmin

Research Psychologist and Author of “This is Your Brain on Birth Control” (available on Amazon now).

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