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Three questions about taking the birth control pill (and plenty of answers)

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Anonymous asks:

I had sex with no condom 3 days before I started my period, AND 1 day after I started my period. I'm on birth control BUT I was at the end of my 1st pack I have ever took (taking the non-active pills) and I don't exactly take them at the exact same time every day but pretty close. I was wondering what's the possibility of me getting pregnant considering the circumstances, birth control doesn't take effect until the first month is up, but I'm already taking my inactive pills so that technically means the month is up doesn't it? Also, I was getting ready to start/was on my period, and I have a regular cycle so I don't think there's any way I could have been ovulating but I'm really worried, please help!

And Gail asks...
I'm 16 years old, and I'm on the pill. I've been on it for little over a month, and recently me and my partner have been doing it without a condom (we're clean) since I've been on them for a month now. Question is, I'm not a perfect user. I take my pill within a 30 min. range, never exactly right on time, what's my chance of pregnancy?

And Hockeylover asks...
I've been on the pill for about a year now and I'm sexually active with my boyfriend. This past month I had sex with my boyfriend and the condom didn't break but may have leaked or something because my boyfriend seemed to think that something minor could have been wrong. A few days after that I forgot to take a pill until about 12 hours after the fact. Now, my pill pack is finished and it is time for me to have my withdrawal bleed which has always occurred at the same time. Today, however, I have experienced nothing but minimal spotting, which is unusual.

Also - just for future reference as I was always curious - I know that it is extremely difficult to become pregnant while on the pill as long as it is taken properly. However, if pills were forgotten or whatnot I realize that it is possible to get pregnant but I was wondering whether one would still experience the withdrawal bleed or whether this would not occur (just like a period doesn't occur if someone is pregnant). Does any blood that comes during a withdrawal bleed while on the pill signify that no pregnancy has occurred? Am I at risk?

Heather Corinna replies:

Since there are so many different pill brands, so much information to sort through, and since with adolescents and/or young adults information on some aspects can vary slightly, and we get so many questions about the pill, it seems it's high time to give the most basic rundown I can speaking to concerns about how to take the pill, when it's effective, and when it may not be.

Let's start with a super-simple summary of how combination birth control pills work.

First, take a look at our piece which explains how the fertility and menstrual cycle works, so you have some context. Got the gist?

So, the pill acts to alter that natural cycle so that you don't become pregnant, via synthetic hormones (usually estrogen and progesterone) to contradict your real ones. The pill works to do that in three ways:

  • by keeping your follicles from maturing and your body from ovulating (releasing a mature),
  • by thickening cervical mucus so sperm have a terribly tough time getting anywhere near an egg if by chance one is still released, and
  • by preventing implantation of an embryo by keeping the endometrium thin in the event that both somehow still manage to happen.

At the start of your pill pack, the hormones in your pills effectively have a little chat with your pituitary gland and tell it to suppress FSH -- your follicle-stimulating hormone -- so that an egg doesn't mature, nor will the cells around it grow to form a follicle that releases estrogen at the beginning of your cycle, which would stimulate your body to prepare thicker endometrial lining through the cycle to sustain a pregnancy.

Your pituitary gland (being highly impressionable, you know the type) steps it up and doesn't produce that FSH, so that maturation doesn't happen and the lining of your uterus doesn't thicken the way it would to sustain a pregnancy. At the time your LH surge would normally happen -- around halfway into your cycle -- the way the pill controls progestin keeps that surge from happening, too, which suppresses ovulation. Thus, no egg is released to be fertilized by sperm. As a backup, it's at the same time keeping cervical mucus thick: to get why that matters, imagine trying to push a piece of thread head first through school paste: that'd be quite a challenge, and is what it's like for sperm to try and move through that mucus to get into the cervix.

When you go off your active pills, and into the placebo (inactive pill) period you get your withdrawal bleed, because taking those hormones away allows for the breakdown of a thin uterine lining you had there (and because the pill keeps it thinner, often people on the combination pill experience lighter, shorter periods).

And when you start your next pack, you start that cycle all over again.

But while we know that the pill, in perfect use, is highly effective, we also know that a) some people do become pregnant while on the pill and b) in typical pill use, lower rates of effectiveness have been shown in studies for adolescents than for adults. Here's the scoop on what perfect use is, how to have the pill be as effective as possible for you, what a missed pill is and what you should do, when it's time to worry about pregnancy and when it's not.

First starting the pill and birth control backups

With all BCPs (birth control pills), to be as safe as possible, and in the interest of having as much protection as possible, it is strongly advised to back up the pill with condom use when using the pill as birth control.

Most effectiveness rates for the pill are lower for younger women, usually because plenty of younger women are having to hide the pill and/or be sneaky in taking them, so it's more likely that younger women, rather than older women, will miss pills and/or take pills late, which can reduce effectiveness. Too, younger women who don't tell their general doctors they are using the pill may not be warned in advance about drug interactions with the pill and general medications (usually that's only the case with one class of antibiotics and some herbal supplements) or that some illness can reduce effectiveness.

STIs should also be a big concern, especially when you're under 22, since adolescents and young adults are both at the highest risk for STIs of any group, and younger women also are at higher risks of long-term complications from STIs. The pill provides no protection against STIs... and also often seems to provide a bit of a sense of false security in terms of infections, since so many women are most worried about pregnancy. Condoms provide that protection, and in addition, the one-two punch of the pill AND condoms (so long as one is used perfectly, and better still if both are used properly) almost guarantees you will not become pregnant.

If you are NOT going to back up with condoms, and are just starting the pill, we strongly advise you to wait one full cycle of active pills before using ONLY the pill as birth control, even though for many people, the pill may likely be fully effective within seven days, and for some, even sooner. If you have gone without a backup method in those first seven days and had sex with only the pill, it is advised to call your healthcare provider and ask about emergency contraception. You may also want to consider doing so if you went without a backup in that first cycle.


Two ways to start taking the pill for the first time
A first day start means you start taking the pill on the first day of your menstrual period. With a first day start, the pill may be effective as early as that first day, but waiting one full cycle before going without a backup is strongly advised.

A Sunday Start is when you start the pill on the first Sunday AFTER your period begins (or, if it starts on a Sunday, on that Sunday). When you start with a Sunday start, the pill may be effective as early as within one week, but waiting one full cycle before going without a backup is strongly advised. The Sunday Start method was devised primarily for women who would prefer they have their withdrawal bleeds (your period wile using the pill) on a weekday, rather than on weekends, as it makes that more likely.

Unless your healthcare provider suggests one way of starting is better for you, how you start is your call, based on your preferences. These two ways are ONLY relevant when you first start taking the pill. For every cycle thereafter, you'll start your new pack when you finish the pack before.


What's taking it on time and what isn't?

You want to do your level best to take your pill as close to the same time every day as is possible, ideally within a window of a few hours: if you do that, every day, then you're a perfect pill user -- that doesn't mean you get a gold star (unless you want one, in which case, by all means, star yourself!), but it does mean that unless you have any other misuse you can rest assured you have the highest effectiveness in terms of pregnancy protection possible from your pill.

To simplify that, what's important is not that you take the pill at the EXACT same time every day (as in, "Oh god! I usually take it at 10:32, and it's 11:03!"), but at the same time of day: for instance, always in the morning, or always before you go to bed. That gets pill-taking into your regular routines so that you're most likely to remember to take them. For instance, Gail says she's not a perfect user, but, in fact, she is, and it sounds like our user with the first question is, too. For that matter, even Hockeylover isn't that far off: with combination pills, while you probably don't want to get in the habit of taking them with a 12-hour difference, just because it can be easier to space out pills that way, but she hasn't put her effectiveness at risk.

A "missed" pill is one that was not taken within 24 hours of the last pill you took. A missed pill should always be taken as soon as you realize you have missed it, but there is likely no risk from one missed pill or a need for EC. A "late" pill varies more in definition among various sources, and to some degree from pill to pill, but with any type of pill, if you have taken a pill more than 12-24 hours late, you may want to consider using a backup method of birth control for the rest of your cycle to play it safe.

With ALL pills if you have missed a pill, the right thing to do is to take that pill as soon as you know you missed it. If it's on that same day, take it when you realize. if you realize you missed a pill when you go to take the next day's pill, take both pills at the same time. If you realize you messed up and missed a pill days later -- while still taking the other pills on time -- then take that pill then. The same goes if you've missed two or three pills rather than just one. When you miss a pill, we advise using a backup method of birth control for the rest of that cycle.

If you've missed more than three, with most pills, you'll want to wait to take any more pills until the following Sunday, then just start a new pack entirely, but use a backup for that cycle as well as the time in between. If you have missed several pills and have had sex in that cycle without a backup method, we advise emergency contraception. When in doubt, always contact your healthcare provider or pharmacist and ask what to do.

How do you know if you become pregnant while on the pill?

The same way you would if you were not: you've really just got to take a test. The most common symptom of pregnancy is a missed or late period, or a period that comes around the time you'd expect it but is very unlike what your period (or withdrawal bleed, when you're on the pill) is usually like. So, when on the pill, if you become pregnant, you most likely will NOT have your withdrawal bleed. But ultimately, you're unlikely to become pregnant while on the pill unless you have not taken it properly, so if you know you have not and are concerned about pregnancy, just take a pregnancy test (and the pill, for the record, doesn't get in the way of pregnancy test accuracy).

I always tell women that I personally feel like a box of a few pregnancy tests in the cabinet is about the cheapest therapy there is: for a pretty small investment, you can have a real sanity-saver handy right when you need it. Even if you think you're just being paranoid, there are times when spending that ten or fifteen bucks to verify you're being paranoid is seriously worth it.

Read up and play it safe.

With ALL pills,read your pill packet information. Pills -- how they're taken, when effectiveness is compromised, what side effects and risks are most prevalent, and the best ways to take them -- can ALL differ from pill to pill. So, be sure if you're on the pill, to read those inserts and to talk to your healthcare provider prescribing the pill for you and ask ANY questions you have: there's just no reason to fly blind with your birth control.

Please understand that more often than not, we DO err on the side of caution here at Scarleteen, both because in many aspects the population we serve is unique (and largely underrepresented in many studies on everything to do with sexuality and sexual health) and because while we are not legally liable for information here, we are certainly accountable for the information we give you and want to be sure we're doing the best we can to help you stay as safe as you want to be if you're going to be sexually active. We always review a myriad of credible sources with our information, and do our level best to look at that information as a whole and draw whatever conclusions from all of it which we feel the most confident will help you to be the most safe.

As usual, we will always encourage you to seek out a second opinion from your healthcare provider whenever you like or feel a need. Don't forget that part of the service your healthcare providers provide is information: when you're starting any medication -- be that the pill or something else -- ask as many questions as you have, don't hold back! It's your doctor or nurses' job to be sure you know how to use your medication properly and understand all you can about it.

written 27 Jul 2007 . updated 27 Jan 2014

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