Red States vs Blue Pills

August 21, 2008 5:25 PM

Dumb birth control pill question: why don't I need to use a backup method while taking the sugar pills?

I started the pill a week ago. The brochure states that if I miss more than two days of the pill, I MUST USE A BACKUP METHOD OF BIRTH CONTROL OR I MIGHT GET PREGNANT (It really is in all caps). But during the "period" week, when you're missing seven days of active pills, no backup method is necessary. Why? What's the difference, especially when I'm supposedly allowed to reschedule the inactive week anyway?

I'm on Ortho-Cyclen, so there's no funny business with varying levels of hormones - all the pills are the same, except Week 4.

What got me wondering about this is that I inadvertently began taking the pill a week before my actual period, because I was spotting and mistook it for Day 1 (my cycle is super irregular, which I'm hoping to correct with the pill). So now, my actual period is here (I'm still taking the active pills), and I was thinking about putting off the sugar pill week for four weeks so I don't have to deal with this again so soon.

But when I take the sugar pills, how is that different from just missing pills? Are they assuming you won't have sex while you're bleeding?

I really, really, really, really, really don't want to get pregnant.

(Anonymous due to the hysterics that would ensue if by some hiccup of the cosmos my mother were to find out that her 27-year-old daughter is having premarital sex.)

posted by anonymous to health & fitness (25 comments total)

I always thought it was because if you skip a couple pills in the middle, it may cause you to ovulate, which is when you get pregnant. During the 7 days you aren't taking a pill, you have your "period", which isn't really a period because you didn't ovulate, but your uterine lining flushes nonetheless. No ovulating=no babymaking.
posted by dpx.mfx at 5:32 PM on August 21, 2008

Wikipedia says...

"The purpose of the placebo pills is that the user can take a pill on every day of her menstrual cycle, remaining in this daily habit even during the week without hormones. Placebo pills may contain an iron supplement, as iron requirements increase during menstruation.

Failure to take pills during the placebo week has no effect on the effectiveness of the pill provided that daily ingestion of active pills is resumed at the end of the week."
posted by Effigy2000 at 5:33 PM on August 21, 2008

What dpx.mfx says. You're not going to ovulate during your period week, and no ovulation means no egg, which means no babies! This site kind of explains it.
posted by SoftRain at 5:36 PM on August 21, 2008

To help you keep on your ritual of taking your pill.
posted by Toekneesan at 5:39 PM on August 21, 2008 [2 favorites]

Forgive the bumbling male answer but you take the sugar pill during your period, which is a process of shedding the nice uterine lining you've been building up, the function of which is to serve as an anchoring surface and blood supply for a fertilized egg, right? So basically a short answer is that it's mostly impossible to get pregnant during your period whether you're on the pill or not. The pill keeps you from ovulating, and even if you did ovulate during your period, and even if that ovum was fertilized, there would be nowhere for it to find purchase.

I'm partly saying all this to find out if I have it right. Someone correct me if I'm wrong!
posted by scarabic at 5:41 PM on August 21, 2008

The above is correct. The active pills keep you from ovulating. The sugar pills keep you from needing to change any part of your daily habit (and can serve as a useful way for you to plan "events").

If you "really really really" don't want to get pregnant then you just want to avoid futzing around with taking certain pills now and certain pills later and so forth. Find the pattern and stick to it. When you have gotten in sync with the pills, you can have more faith that they are working as advertised.

After you get the hang of it, you can experiment with just avoiding the sugar pills, and avoiding menstruation most of the time. It is not uncommon to only deal with frumpy week once a season instead of once a month (but talk to your doctor about it!).

Anyway, I think your question is answered. Use a backup method until you and the pills are jiving, then you can have more faith in them.

Happy pre-marital sexing! (I suspect that is the _only_ "happy" sexing one actually gets)
posted by milqman at 5:55 PM on August 21, 2008

The thing is that you need to be off the hormones for longer than seven days -- or at least for certain days in a longer-than-seven-day-span -- to get pregnant. That's why missing a few days can get you in trouble; say you miss two days three days before the sugar pills start. Now you've got 12 days of less-than-perfect hormone levels, which may be enough time for an egg to get prepared and for you to ovulate.

So: those two days are fine. Combined with the hormone-free week, not fine. So if you miss some days, delay the sugar pills by a few weeks. And be extra careful taking the pills in the days after the sugar pills. Or just skip the placebo week altogether!
posted by wyzewoman at 5:55 PM on August 21, 2008

But during the "period" week, when you're missing seven days of active pills...

The sugar or sugar/placebo pills are not active - they have no hormones in them at all, but as others have said, are included in birth control packs only to keep you in the habit of taking a pill each and every day (presumably at the same time).

Once you finish the three weeks of active hormones (usually these are a different color, or marked differently in your pack than the inactive/sugar/placebo pills), you can continue to take the seven pills without hormones, or you can skip them - as long as you start Day 1 of a new pack on the right day - every 28 days. Or, 8 days after taking the last active pill in your pack (7 inactive days + the next day).
posted by raztaj at 6:02 PM on August 21, 2008

As others have said, those aren't active pills, they're sugar pills. A placebo week was built into the Pill from the beginning, because the engineers of hormonal birth control believed that women "needed" to have periods, for reasons both physical and psychological. It's unnecessary, which is why so many women now choose to skip the placebo week. The bleeding you experience that week isn't a period at all: it's spotting induced by hormone withdrawal. There is no physical need for this withdrawal bleeding whatsoever. You don't shed your uterine lining during that week because the uterine lining doesn't build up while you're on the Pill. The Pill: Myths and Misconceptions is a useful link:

When a woman takes the Pill her normal menstrual cycle is interrupted. In effect, the Pill tricks the body into believing it is pregnant. When the Pill was being developed, however, it was felt that women would find the lack of a normal menstrual cycle disconcerting. Many women, for example, rely on their regular menstrual period for reassurance of not being pregnant. Consequently, it was decided to have the Pill consist of 21 days of active pills (pills containing the hormones), followed by a pill-free interval of seven days (either no pills or sugar pills). The rapid decline in the artificial hormones which occurs in the pill-free interval results in a 'withdrawal bleed', which somewhat resembles a menstrual period and is often still referred to as a 'period' for simplicity. It is important, however, for women to understand that when they take the Pill the bleeding which occurs during the pill free interval is not a menstrual period. Similarly, women should be aware the current packaging of the Pill (21 active pills, seven day pill free interval) was developed primarily for acceptability reasons and not because of any physiological reason.
posted by Powerful Religious Baby at 6:08 PM on August 21, 2008 [3 favorites]

This is one of the clearest explanations I've ever seen on how this works.
posted by Sidhedevil at 6:10 PM on August 21, 2008

follow-up from the OP

OK, let me explain again, because I think my question must not have been clear.

I know that the sugar pills are inactive, which is why I equated them with missing active pills - it's the same thing. Either way, you're not getting hormones.

I also know that the "period" you get during the sugar-pill week is actually a withdrawal bleed caused by the sudden drop in hormones.

My question relates to the phrase "the middle" in this answer: "I always thought it was because if you skip a couple pills in the middle, it may cause you to ovulate, which is when you get pregnant."

When is "the middle" when you're on the pill? Normally, it would be approximately 14 days after your period. However: first of all, you're not actually getting your period, because you never ovulated. Second of all, if you use the pill to manipulate your cycle, like by putting off the inactive week for a week, or a month, or five months, then there's no "middle" because there's no real "cycle." In that case, I don't understand why you're allowed to take seven fake pills in a row without fear of getting pregnant, but if you accidentally forget to take a couple of active pills, you *could* get pregnant. Isn't it the same thing?

wyzewoman came closest to answering my question. But say you're only taking the sugar pills every four months because you only want your period three times a year. Am I correct in understanding that within those four months, if you for some odd reason forget to take your pill for up to seven days, you won't get pregnant?

posted by jessamyn at 6:36 PM on August 21, 2008

In any given 28-day cycle, you only need to take 21 continuous days of active pills to be fully protected, yes.

But you can't spread out the days without active pills--that will disrupt the protection.

That's why people who miss two or three days of active pills in a 28-day cycle should use backup methods.

If you take 84 straight days of pills, and then don't take any pills for 7 days, you will be protected. However, if you don't start back onto the active pill cycle then, you will not be protected--the protection isn't cumulative, so it's not like you can go 84 days on/28 days off (to use a reductio ad absurdum).

And you can't take 84 straight days of pills, then not take any pills for 5 days, then take pills for 5 days, then not take any pills for 2 days--you will not be protected, because you need 21 continuous days..
posted by Sidhedevil at 6:43 PM on August 21, 2008

Wow, people. Is anyone actually reading the question? She wants to know why you have to worry about missing just two active pills in a row during the first 21 days, but you don't have to worry about going 7 consecutive days without active pills during days 22-28. Anonymous, I totally get why that seems to not make sense. I don't have a great explanation, but this info from Sidhedevil's link comes close.

When you take the pill, the synthetic hormones send a different set of signals to your reproductive system entirely, so that you do not ovulate -- release that egg -- so that your vaginal secretions become and remain thicker (to make it tougher for sperm to get to an egg in the case something went amiss there), and so that that endometrial lining doesn't build up as much (in the case that the other two modes go awry, that would make it really tough for a fertilized egg to implant). That's three different ways to protect you from pregnancy, and even just one of those ways is often enough.

The reason why you don't have any extra risks during that placebo week is because of all of the things the pill has done in the three week prior, and which it will do once you start taking it again. During that week, you don't need pills because they've already prevented ovulation and fertilization, so you couldn't become pregnant during that period of time, as without all those preceding signals to be fertile, you can't suddenly become fertile in that week.

I also did some research in the book Taking Charge of Your Fertility by Toni Weschler, which comes very highly recommended by fellow mefites. It doesn't specifically address your question, but it does discuss women who quit taking the pill in order to get pregnant. It says the delay between stopping the pill and becoming fertile again depends on your body's ability to show "the classic buildup of fertile-quality cervical fluid." (Incidentally, it says the return to fertility can be almost immediate, or may take months to years, depending on the woman.) That seems to corroborate the info above about vaginal secretions being the wrong kind to let sperm through.
posted by vytae at 6:57 PM on August 21, 2008

Apologies, anon, my answer was partly directed toward scarabic, who expressed confusion. Sidhedevil's link provides a good explanation of the Pill's processes.

In that case, I don't understand why you're allowed to take seven fake pills in a row without fear of getting pregnant, but if you accidentally forget to take a couple of active pills, you *could* get pregnant.

Because the active pills contain the necessary hormones to prevent ovulation. Timing matters here; you must maintain steady levels of the appropriate hormones in your body in the weeks before ovulation is set to happen. If these levels are disrupted, ovulation can occur. Your body wants to release an egg every month, so a three week pill cycle is appropriate. By the time you reach the placebo week, the hormones have already done their primary work: ovulation has failed to occur, the uterine lining is thin, and your cervical fluid is hostile to sperm.
posted by Powerful Religious Baby at 7:37 PM on August 21, 2008

She wants to know why you have to worry about missing just two active pills in a row during the first 21 days, but you don't have to worry about going 7 consecutive days without active pills during days 22-28.

I felt like I explained that in my second comment--you need 21 continuous days of pills to ensure that you've suppressed ovulation.
posted by Sidhedevil at 7:45 PM on August 21, 2008

I felt like I explained that in my second comment--you need 21 continuous days of pills to ensure that you've suppressed ovulation.

I'm still confused by this. Anon, I hope you don't mind me jumping in on your question to get some clarification.

Does this mean that 21 days of hormones does such a good job of suppressing ovulation that your body can't "recover" enough to ovulate during 7 days off the hormones? Or would your body just not be trying to ovulate during those 7 days due to its own internal schedule? Or something else?

If a woman did decide to take active pills for 3 months to skip menstruation, would 2 missed days no longer be considered a problem as long as there were at least 21 consecutive days of active pills between any occurrences of missed pills? For example, would she be safe with 40 days on active pills, 2 missed days, another 27 days on active pills, another 2 missed days, etc?
posted by vytae at 8:28 PM on August 21, 2008

Does this mean that 21 days of hormones does such a good job of suppressing ovulation that your body can't "recover" enough to ovulate during 7 days off the hormones?

Yes! That is correct.

If a woman did decide to take active pills for 3 months to skip menstruation, would 2 missed days no longer be considered a problem as long as there were at least 21 consecutive days of active pills between any occurrences of missed pills? For example, would she be safe with 40 days on active pills, 2 missed days, another 27 days on active pills, another 2 missed days, etc?

Yes, this would also be safe for pregnancy prevention.

Also, someone quoted something upthread that said that "In effect, the Pill tricks the body into believing it is pregnant." This is false--there are no pregnancy hormones in the pill. The pill works by *suppressing ovulation* through artificially stable hormone levels.
posted by Violet Hour at 9:41 PM on August 21, 2008

Just FYI, you can't skip the sugar pills and avoid periods with all types of pill. Different pills have different hormone levels throughout your cycle, and if you try manipulating your period with the wrong kind of pill, you may find the results unsatisfactory.

Don't do this without making sure you've got the right kind of pill.

The More You Know....
posted by padraigin at 10:30 PM on August 21, 2008

As told to me by my doctor: The body won't release an egg while the uterus is shedding. However, it is possible to still get pregnant during menstruation if an egg has been released just before shedding. It's rare, but there is still a chance. So if a few pills are missed in week 3, then yes, pregnancy is slightly possible during menstruation/placebo week.
I recommend using a backup method until your cycle stabilizes. Don't be surprised if you have another lighter period when you start taking your placebo pills.
posted by idiotfactory at 11:24 PM on August 21, 2008

To really appreciate how the pill works, you have to know a little bit about hormones and feedback regulation.

In a normal menstrual cycle, without BCP, the first two weeks are characterized by a slow increase in the levels of Follicle Stimulating Hormone (FSH), which signals several eggs to start preparing for ovulation -- you actually burn through several hundred eggs each month, your body just picks one lucky winner to actually ovulate, the rest die.

This activity in the stimulated eggs causes them to start producing estrogen in increasing amounts. At around Day 14 in the cycle, the estrogen levels reach a threshold level that is high enough to cause an acute release of another hormone, Luteinizing Hormone (LH), as well as a spike of more FSH. This causes ovulation to occur, and an egg is released.

Once the egg is released, the "nest" for that egg that remains in the ovary (called the corpus luteum) continues to pump out estrogen, as well as another hormone, progesterone. The progesterone signals the endometrial lining to start secreting mucus to make the passage of sperm easier and make the lining more receptive to implantation of a fertilized zygote. In addition, the progesterone feeds back to the pituitary gland in your skull, where FSH and LH are made, and SHUTS OFF their release. This is important, because otherwise more than one egg could be released, or future eggs could be released while you are already pregnant.

If you get pregnant, there is enough time from ovulation to before menstruation for the new fetus to start making its own hormones, which tells the corpus luteum to continue to produce progesterone, which helps to maintain the lining of the uterus, and so you miss your period. If you don't get pregnant, the corpus luteum eventually shrivels up and stops producing progesterone around day 28, and so the endometrium, lacking the proper signals to continue living, dies and sloughs off.

The key ingredient in oral contraceptives is the progesterone (or rather, a synthetic version of it) that mimics the effects of real progesterone. Thus, it turns off the FSH and LH hormones which are so key to the ovulation step. In this way, it could be said that the pill tricks your body into thinking its already pregnant, but a more accurate description is that it tricks your body into thinking that it has already ovulated.

It is ok to take off the week for your withdrawal bleed because you still have a build-up of endometrium in your uterus that naturally wants to come out. Due to the screwy nature of the hormone levels in someone taking contraception, it will normally be less than a natural menstruation, but it still should come out, at least once a season. You won't have a release of FSH/LH then because it takes about 2 weeks for them to get "charged up" to make an effect on your ovaries. Also, even if you did ovulate around day 28 +/- a few days, your endometrial lining is in such a state of disrepair that even if an egg were to be fertilized (itself a difficult task, as the dying endometrium sets up a pretty toxic environment for sperm and eggs), there wouldn't be anywhere for the egg to implant.

On the other hand, taking a couple days off of the pill in the middle of the cycle may give your body the time to recover sufficiently to pump out a new egg, because that is the time that the body wants to be ovulating, and there are things hormonally that you can't control for as much. When you start blocking the actions of a hormone, your body can respond by making more receptors for that blocked hormone (i.e. making itself more sensitive to that hormone), so you may be primed for reacting to (and thus perhaps ovulating with) even a small rise in your FSH/LH after a few missed pills.
posted by i less than three nsima at 6:30 AM on August 22, 2008 [54 favorites]

The pill is good, but i do know a woman who got pregnant while on it. I don't know if she skipped a pill or not, but my point here is that until you are comfortable enough with your partner that getting pregnant would be something you could deal with, consider using a backup method, like a condom or the sponge.

Also, familiariaze yourself with Plan B just in case (you can get it at the pharmacist, you take the pills the day after you realize you skipped a pill and had sex, and they will prevent pregnancy).
posted by Penelope at 7:14 AM on August 22, 2008

The pill is good, but i do know a woman who got pregnant while on it.

Yes. No contraceptive method is 100% effective, including vasectomies and tubal ligations. Perfect use of oral contraceptive pills is more effective than vasectomies, and slightly less effective than a tubal ligation.
posted by Sidhedevil at 3:09 PM on August 22, 2008

Can I ask for a clarification, i less than three nsima? I was under the impression that bleeding occurs when you take a break from active pills because the sudden disruption of hormone levels causes the uterine lining to destabilize just enough for a small amount to be shed, not because "you still have a build-up of endometrium in your uterus that naturally wants to come out." It used to be considered dangerous to take active pills year round so that withdrawal bleeding never occurred, but continuous-use hormonal contraception is now generally considered to be fairly safe.
posted by Powerful Religious Baby at 7:55 PM on August 22, 2008

The disruption of hormone levels during the "off-week" of traditional oral contraception is what causes the withdrawal bleed, but what you are bleeding out is the uterine lining that has grown during the past few weeks due to the estrogen and progesterone derivatives that are contained in the pill. The amount of hormone that the body gets from the pill is not as much as what is typically found in a woman not on contraception, so the endometrial growth - which is directly associated with estrogen levels - is usually less robust. That is why OCP is frequently prescribed to women who have particularly heavy periods, it can often result in a lighter monthly bleed.
posted by i less than three nsima at 3:31 PM on August 26, 2008

Jumping in as someone with irregular periods which the docs attempted to control (along with other issues) via BC pills:

The one thing that gets tucked waaaaay into the fine print: If your cycle is historically irregular, you should always use backup protection - even when on the hormone-active pills - until your cycle is predictable and has been for at least a couple of months (ideally 3). If it doesn't become predictable, go back to your doctor. You may be given a different type of pill or moved onto a different type of BC to go along with the hormonal control of the pill.

Keep in mind that even if you have super regular periods, the pill is only 99% effective even for those using it as intended/per instructions. If you're not ready to be pregnant but want to have sex, two forms of protection is always a good idea.

There are specific formulations of the pill for those who want to avoid a cycle for a few months. These are typically monophasic and include Seasonale and Seasonique.

This article discusses efforts to get Lybrel approved (kind of contentious, since it will suppress menses for a longer period of time and there is no long term study of elective suppression of menses; many doctors are hesitant to support it without more information), and also mentions a few of the other pills available to achieve similar results.

This link discusses the various pill categories and some standard formulations for each.

Believe it or not, Yahoo! has a remarkably complete listing of current bc pill options, details, concerns, and warnings.
posted by batmonkey at 1:29 PM on August 30, 2008