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A Birth Control Pill Five by Five

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Sensei Martini asks:

I want to begin taking the birth control pill for the first time. Is it possible for me to start taking my first birth control pill on the SECOND day of my period? I won't be having unprotected sex. But if I start taking the birth control pill on the 2nd day is it less affective? And also after taking the birth control pill for a series of time, when is it 95% affective? It obviously doesn't begin on the first day I start right?

Heather Corinna replies:

It's fine to start on day two. Really, it's okay to start at any time in your cycle.

It's just that the pill will become fully effective more quickly if you start at certain times rather than others. If you start within the first six days of a period, your withdrawal bleed (the "period" that happens while using the pill) will tend to synch up with your existing periods and there may also be less breakthrough bleeding or spotting while your body gets used to the pill.

If a person starts a hormonal method like the pill between day one of their period and the Sunday after, their method will usually be fully effective after 7 days of use, so long as they take pills consistently and correctly and keep on taking them consistently and correctly after that first week. In other words, if you take it right those first seven days, then ditch it or miss a bunch of pills, you may not be protected, including from sex you may have had during the time you took them correctly. The pill may even be effective immediately for those who start it on day one or in the first six days, but we advise being cautious and backing up for the first week, especially since it can be so easy to take pills late when you're just starting use, like with any medication.

A benefit to doing a Sunday start some people appreciate is that it makes it more likely your withdrawal bleed will start every cycle towards the start of the week rather than on the weekends. So, if that sounds good to you, you may want to wait until that first Sunday to start.

If a person started past that timeframe of day one to day six, it's advised they use a backup method of birth control for the first full pack of pills, because starting mid-cycle may mean ovulation is already happening or won't be suppressed.

In terms of effectiveness, birth control pills (the same goes for the patch and the ring) are over 99% effective in perfect use and 92% effective in typical use. Lower typical use rates than those have been reported for adolescent pill users, especially after the first few months of use, but those are only relevant if you don't use your pill properly, as directed. When is it 95% effective, like you asked? Given the effectiveness rates, when someone is between perfect and typical use.

I don't know where you got that 95% figure. However, when I do contraceptive consults with people online and in person these days, I'll often suggest people figure the average of a perfect and typical use rate for a method is a good figure to consider in choosing if a method is right for them since perfect use of rates we control as users can sometimes be difficult to attain.

So you're more filled in, and for other users who often ask us these kinds of questions, here's some additional information about the pill and effectiveness rates.

With any contraceptive method, we have two levels of effectiveness: perfect use and typical use. Perfect use means a method is used exactly as directed; correctly and consistently. Typical use means the way people more often tend to use it in daily life, which is often imperfect because...well, because people and our lives are rarely perfect.

With a combined birth control pill, perfect use means taking your pill correctly (as in, you put it in your mouth and swallow it) around the same time of day every day, like in the mornings or the evenings, and no later than outside a 12-hour window of time for any given day. In other words, if you take a pill Tuesday at 8 AM, then take Wednesday's pill at 11 at night, that pill would be late. With a minipill, perfect use means taking it correctly every day within no more than a three-hour time window.

What does correct and consistent mean? It means you read the directions in your pill packet -- the folded paper insert that comes with that medication -- and follow those directions to the letter, then take your pills each and every day, without fail. It means you don't do things like take them for one pack, then skip a couple weeks of another pack and start again; that you don't take pills all willy-nilly or try and take them by sticking them between your toes instead of in your mouth. It means you never take more than seven days off during the placebo (inactive) pills in the pack, and don't try and move the inactive pill period to a time other than at the end of the three weeks (or more) of active pills. If you use a pill that is multiphasal (if your pills come in more than two colors, one for active pills and one for the week of placebo pills), that additionally means taking the right pill on the right day or week, not just pulling pills from anywhere in the pack.

You want to be sure you're not taking other medications with your pills that could make them less effective, so if you take another medication besides the pill, just be sure to have whoever fills your prescriptions check that for you, and if you ever get another mediation you don't take now, check in again about that one.

Typical use often involves a person taking pills at different times of day, taking a pill late, outright missing a pill or more than one pill (especially if a missed pill isn't made up as soon as it was known to be missed), or using the pill accidentally with another medication that isn't a sound mix. Missing pills or taking them late is the most common way the pill fails. While women of all ages commonly take pills late or miss a pill in a pack sometimes, for younger women in particular this can be even more common. Some studies show typical use rates as low as 30% (Fam Plann Perspectives, Mar-Apr 1999;31(2):56-63. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth, Fu H, Darroch JE, Haas T, Ranjit N.) for adolescent pill users.

While some of the lower typical use rates for younger people are probably influenced by greater fertility, for the most part, it's just about how well you or others do -- or don't -- take the pill. In other words, whether or not you have a lower rate of effectiveness is mostly within your control. If you take pills as directed, you will be closer to that perfect use rate and nowhere near a figure like 30% effective.

Should it turn out that you feel like or discover you're one of many people who have a tough time taking a pill around the same time every day, you have other similar options in contraceptives that don't require daily use. A lot of people stick with the pill even when it isn't a good fit for their lives because they don't realize there are other methods that are just as safe which would be easier for them to use properly. Sometimes younger people are more inclined to because they got the pill by talking about acne or menstrual issues, and don't want to ask about other methods because they'd have to disclose they're sexually active. Should that be a concern, know that in most areas, your privacy is protected (so you can be honest and it won't be shared with parents or guardians), and in the United States, if you use Title X clinics, like Planned Parenthood clinics, that protection is mandatory for their funding. For you in Sri Lanka, Sensei, you can check out this link for additional services available to you, and can check in with them about privacy protections: http://www.fpasrilanka.org/clinic.php

sizzley asks:

My birth control prescription ran out a month ago. It took me a few weeks to get it refilled, but I kept waiting for my period to restart the pill. So basically I have been off the pill for a month. I haven't had my period this month (about a week late now)- I took a pregnancy test (we always use condoms too)- it was negative. I still want to be on the pill, but the instructions are to do a "first-day" or a "sunday" start, but since I'm not having a period, can I just start taking them again anytime? Will that re-regulate my cycle and prevent pregnancy? Or do I HAVE to wait for my period to show up before starting the pill again- I've heard that can take months.

You can start again any time you like. You just want to be sure to stick with using the condoms during the first full pack to prevent unwanted pregnancy since you took more than seven days off and are starting at a time other than within the first few days of your period. We often hear from users who've had issues like this with prescriptions running out, and it's one way a lot of people can wind up pregnant, especially if they're not using condoms or another backup method. So, do all you can to be sure you always have those pills on time. Maybe that means putting a note on a calendar to call for a new prescription a month or two in advance, or asking your healthcare provider for longer prescriptions to be sure you're covered, but no matter how you do it, it's good to try and avoid that situation if you can.

If you still don't have any bleeding or spotting at all in the next couple of weeks, I'd suggest doing another pregnancy test, just to be sure.

klutz0705 asks

I have been on the pill for almost a year, and am sexually active. Last month, I took the pill at the same time every day. I got my period as usual on the third day of the inactive pills. On the last day of my inactive pills, I had sex. I started a new pack the next day as usual, and three weeks later should have gotten my period. I have not had sex since starting this month's pack of pills. However, I missed one day's pill this month and took another several hours late. Could this make my period late?
What are the chances that I could be pregnant?

Flamexofxchaos asks:

I recently stopped taking my birth control (ortho tri-cyclen) and had unprotected sex a week later. I have yet to get my period and it has been a week and half since, so I was wondering what is the possibility that I might be pregnant?

When it comes to questions about when a given method will be exactly this percentage or that percentage effective, we just can't give those. No one can. Same goes with what, exactly, the chances of pregnancy are with a given pill mishap.

However, missing pills, taking them late or not taking them at all is not correct use of the pill. Even one missed or late pill means we're talking about typical use effectiveness at most, possibly lower than that depending on how many pills were missed or late as well as how fertile a given person just happens to be, something we just can't know or predict. If and when someone has stopped using a method altogether, they need to figure that method can't offer them protection anymore. In the case of the first question, it may just be the missed pill and late pill threw a withdrawal bleed off-course, but if you have been having the kinds of sex that can create a pregnancy, it'd be wise to take a pregnancy test. With the latter, if another week or two goes by without a period, you'll want to take a test, too.

Every day people ask us how effective a given method is, or what percentage of risk this situation or that one presents, and the best we can ever do is work with what figures we have from sound sources of data giving the same kind of effectiveness rates I gave you up top there.

Even saying any given method is whatever-percent effective when someone says they used one and want to know how effective it was or may have been is a bit of an iffy answer, because those rates aren't figured out that way. Effectiveness rates, perfect and typical, are calculated for one year of use, the first year of use, not for one time or day. They're also calculated for every 100 people, not one person. When we or other educators or clinicians say the pill is 92% effective in typical use, that means that of every 100 people using the pill typically, 8 reported becoming pregnant during that year. Too, the people in these studies and surveys vary a good deal per their health and fertility, age, relationship status, sex lives and overall lifestyles. That means that for any one person, at one given time, the rate could be and may be a little higher or a little lower.

Why can't we -- either us, directly, or we as a reproductive health community -- give rates for this method or this percent on this day or this circumstance?

Well, because we can't gather data like that about every single day for every single person. We also can't know what chance of pregnancy anyone in the broad data we have would have had WITHOUT using those methods, since we don't all have the same chance of pregnancy; not each person, and not any one of us, alone, on every day of the year. Fertility varies a lot, both from person-to-person and from day-to-day. Some people have a greater chance of becoming pregnant than other people do. That varies widely based on a lot of factors, but the biggies for those most likely to become pregnant are age (people under 30 are usually more fertile than people older than 30), the regularity of menstrual cycles (the more regular cycles are, the more likely pregnancy is) and frequency of intercourse (having sex more often = a greater chance of pregnancy).

We know from studies that in one year of having intercourse without any kind of birth control method being used, around 80-90% of female-bodied, fertile people will become pregnant. But that's one full year, not one instance, and we can't just divide that one year figure by 365 days to get a rate for any given day because, again, our fertility isn't the same every day of a year. Since we can only be so specific, we refer to sound sources who give sound estimates based on a year at a time for many people.

But when it all comes down to it, we have to just figure that a method being as effective as it can be just boils down to correct and consistent use. No single method is 100% effective, so if we're having the kinds of sex that present a risk of pregnancy we have to know there is always some risk. If we're using a method like the pill as correctly and consistently as possible, that risk is really very low. If we are not using it correctly or inconsistently, the risk increases, depending on how incorrectly or inconsistently we're using it. Taking a pill or two late, or missing one pill you make up the next day probably still has a person in the typical use range, while taking pills late routinely, missing more than one pill, or taking more than a week off between packs (and still having sex) often means a person has less protection than the typical use rate.

superstar8 asks

Me and my fiance are both virgins. We are both free of STDs. I want to get ready for our married life together. We do not want to have kids right away, we are thinking of waiting five or so years for that. If I am on the pill, do we still need to use condoms?

Whether or not you choose to use the pill without condoms or another backup method per pregnancy prevention tends to depend on a) how properly you know or think you can use the pill and b) if you feel like the level of effectiveness your typical or perfect use can give you is high enough for you, personally. Some people would prefer not to become pregnant at a given time, but would still welcome and be ready to handle a pregnancy if it happened. Others really, really don't want one for any number of reasons, or know a particular time would be seriously bad for them or their family. Where you fall on that spectrum is a big player in this choice. Of course, there are more effective methods than the pill -- like the IUD, Depo-Provera or the contraceptive implant -- for those who want more protection than the pill provides (or perfect and typical use rates that are more similar) but only want to use one method.

I always want to make sure everyone knows about dual contraception, or what we like to call "The Buddy System" here: that's using more than one method of contraception as a habit, which some of the users in this piece are already doing or planning to do. Most sexual and reproductive health and advocacy organizations support the use of two methods, not just one. That's usually particularly advised with methods like the pill that are very reliant on a user administering the method themselves (unlike something like an IUD or a contraceptive implant).

Reproductive and sexual health organizations often recommend condoms as a specific backup method to help prevent the spread of sexually transmitted infections (STIs). The pill doesn't offer any protection against sexually transmitted infections which can be just as much of a risk -- sometimes more so -- as pregnancy is.

I'm not trying to second-guess anyone's relationships or history. However, one thing the consistently high young adult STI rates tell us is that often, people assuming there to be no STIs without testing often assume incorrectly. Just so we're all on the same page, people being "virgins" doesn't automatically mean everyone is STI-free, especially if the definition of virgin is only about vaginal intercourse, as other sexual activities pose risks of infections, too. Sometimes it's also very hard for people to be honest about their sexual history when the stakes are high, like if one partner really, really wants the other to have had no past sexual experiences.

The way we can accurately know our STI status is through STI testing. So, unless partners have recently been tested, it's just not sound to assume everybody's free and clear of STIs just based on sexual history or what someone says their history is.

Beyond STI protection when backing up with condoms, what can dual contraception do for you? It ups your protection, no matter what. You can see how much it can do that with various combinations here. It can cover your butt if you do forget a pill or take one late. If you're using two methods, not only do you get extra physical protection in case of snafus, you also get some peace of mind if you do make any slip-ups. Pregnancy scares can just do a serious number on anyone's life, so being able to say, "But wait! We were also using a condom! Phew!" can be a big comfort and help prevent a lot of freakouts. As well, when one partner is in charge of one method, and the other has one they also get to be in charge of, it can be one of many ways to help partners share responsibility and ownership over sexual and reproductive decision-making, which a lot of people find empowering for themselves and their relationships.

For those who have already been tested and know their status, or who haven't been, but still want a backup that isn't male condoms, female condoms, cervical barriers, the sponge, withdrawal and spermicides are other methods that can safely be used with the pill.

For more information on the pill, how to use it, and other methods of birth control, see:

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