The pill

What types of pills are there?

There are over 50 different types of pills in Germany. You may have to try several different types of pill until you find one that is right for you.

Most pills contain estrogens and progestins, which is why they are also called combination products.

There are combination preparations in which all tablets contain the same dosage. They are called single-phase preparations. You can recognise them by the fact that all pills (almost always 21 pills, rarely 22) come in same colour.

However, there are also pills that contain 21 or 24 pills of the same colour and 7 or 4 pills of a different colour. The pills of a different colour are so-called placebos, they do not contain any active ingredient and are only intended to make it easier to take a break.

In addition, there are 2 and 3-step preparations, wherein the pills contain different amounts of estrogens and progestins. The pills then have different colours. Here as well, there are preparations with placebos intended for break.

How safe is the pill?

The pill is a very reliable method of contraception, but only if it is always taken regularly and as per directions. Out of 1000 women who take the pill for one year without any errors, only one woman becomes pregnant.

Various mistakes, such as forgetting pills, diarrhoea, vomiting or drug interactions can make the pill less effective and therefore less safe.

Various combination products do not differ much with regards to their safety, they are all equally reliable.

How should I take the pill?

The are packs that contain one or more "blisters": these are cards containing the pills for one cycle. Most preparations contain 21 pills, sometimes 22 or 28 pills.

You take one pill every day at about the same time each day until all the pills in one blister are used up. Then take a break. If your preparation contains 21 pills, take a seven-day break; if you take 22 pills, take a six-day break. Then start taking the pills from the next blister. The contraceptive protection also continues to be effective during the break. If your preparation contains 28 pills, start with the next blister without a break.

Most women get a bleed during the break from taking the medicine. It is usually weaker and shorter than the usual menstrual period. However, it does not matter if and when the bleeding occurs. In any case, you must start taking the pill again on the 7th or 8th day . You are not supposed to take the pill after the bleeding.

It does not matter at which time of the day you take the pill.

What side effects does the pill have?

Most women can tolerate low-dose pills without any problems. However, sometimes - especially during the first three months - there can be side effects because the hormones interfere with the woman's cycle. If the side effects are very unpleasant and last longer, you should ask your doctor for an alternative.

If you take the pill, your bleeding may change: You may bleed in between or the bleeding may stop altogether. Bleeding usually becomes shorter and much weaker.

Sometimes nausea and dizziness can occur. Some women also experience breast tenderness, abdominal pain, headaches or depressive moods. Changes - usually a decrease - in sexual appetite are also possible.

Many women fear that the pill will make them fat. As a matter of fact, only a few women gain weight when on the pill. Usually it is only two to five kilos at the beginning, which often goes away after the initial period of settling in. For most women, the weight changes only slightly or not at all. There are no special "slimming pills" for this.

Pill and thrombosis

A rare but serious side effect of combined pills is the involvement of a thrombosis. Thromboses are blood clots, mostly in the deep veins of the legs, which can lead to life-threatening pulmonary embolisms. However, thromboses are overall very rare events.

In most cases, thrombosis under the pill occurs during the first six to 12 months of taking the pill, most often right at the beginning (during the first three months). If you take the pill for a long time, the risk of thrombosis is hardly higher than before the pill. Therefore, there is no reason to change the pill, if a woman has been taking it for a long time and has good tolerance for it.

The thrombosis risk of different pills varies slightly depending on the progestin they contain.

In case of the first prescription of the pill, the Federal Institute for Drugs recommends prescribing pills with the lowest risk of thrombosis unless there are specific reasons for prescribing any other pill.

Arterial thromboses such as heart attacks and strokes are also more common when on the pill, and differences between different pills are not discernible. However, heart attacks and strokes are extremely rare in young, non-smoking women under 35.

When women take the pills for the first time or have more migraines than before, this can be an indication of an increased risk of stroke. In which case, they should stop taking the pill.

Women who smoke, are overweight or have high blood pressure are more likely to have thrombosis or a heart attack or stroke. These women should take a consult from their doctor - whether other methods of contraception are better for them or whether they should continue taking the pill.

Women who take the pill are slightly more likely to develop breast cancer than women who do not take the pill. However, breast cancer is very rare in women under the age of 35. One in every 10,000 women taking the pill has an additional case of breast cancer. For women who take the pill up to the age of 40, there are 19 additional breast cancer cases among 10,000 women in the next 10 years. Ten years after we stop taking the pill, there are no more differences.

How do I get the pill and what does it cost?

For the pill, you need a prescription from a doctor. It is usually prescribed by a gynaecologist, in pro familia counselling centres, or in some case also by your family doctor. With the prescription, you can buy the pill in all pharmacies.

Statutorily insured girls under the age of 22 do not have to pay for the pill, as the statutory health insurance covers the costs in full. If they are between 18 and 20 years old, a prescription fee of €5 is charged at the pharmacy.

Women who are 22 years of age or older must pay for the pill completely by themselves. A three-month pack costs between 20 and 40 €, six-month packs are usually cheaper.

Social welfare recipients and recipients of unemployment benefit II must bear all contraceptive costs themselves. In some municipalities and cities, however, there are exceptions. Hence it is worth clarifying on the spot whether it is possible to cover the costs after all.

Like the pill, the mini-pill is a hormonal contraceptive which does not contain oestrogen, but only progestin.

The hormone in the mini pill causes a mucus plug to form in front of the cervix. The mini pill must be taken extremely punctually, always at the same time. In exceptional cases, a maximum delay of three hours is tolerable. In addition, it needs to be taken every day of the month without interruption; depending on the preparation, there are 28 or 35 tablets in one package.

Most preparations contain the progestin levonogestrel. A mini pill preparation contains a slightly higher dose of progestin desogestrel and also inhibits ovulation. This preparation can be taken up to 12 hours late.

Advantages

The mini pill can be taken by women who do not tolerate the hormone estrogen well or are not allowed to take it because of health risks involved. The mini pill can also be taken by women who are breastfeeding because of its low hormone dosage. The amount of hormone that passes into the milk is small and does not seem to harm the child, according to recent findings. The mini pill is also often recommended for women over 40 years of age, as it has a high level of safety with low side effects.

Disadvantages

The menstrual period is often irregular when taking the mini pill. It is delayed or does not occur at all. There may be light or frequent intermenstrual bleeding, which is medically harmless. Intermenstrual bleeding is the most common reason to change to another method of contraception. Some women complain of breast tenderness, headaches, mood changes or loss in sexual appetite.

Reliability

The mini pill is one of the relatively safe contraceptive methods (see Pearl-Index). A prerequisite for ensuring the reliability of the mini-pill is taking it absolutely punctually every 24 hours. If the mini pill is taken more than 3 hours late, the contraceptive protection decreases significantly, as the mucus droplet in front of the cervix liquefies quickly. The exception is the preparation based on desogestrel (see above), which can be taken up to 12 hours late due to the additional suppression of ovulation.

Some medications, such as certain antibiotics, St. John's wort, anti-epileptic drugs and psychotropic drugs reduce the contraceptive effect of the mini pill. Its impact is also lessened in the event of vomiting or diarrhoea because the active ingredients are not absorbed sufficiently by the body or are excreted too quickly. If you are taking medication, tell your doctor or health care professional that you are taking the mini pill.

Accessibility

The mini pill is a drug and must be prescribed by a doctor after a thorough examination. It is then available in all pharmacies on prescription.

Costs

The mini pill costs between 6 and 17 € per month, depending on the preparation and the package size prescribed. Pills in the 6-month package are considerably cheaper. Depending on the age, additional costs are incurred such as a prescription fee:

Under 18 years of age:

• SHI-prescription: Free of charge - no further fees
• Private prescription: No other fees except the cost of the drug

Under the age of 20:

SHI-prescription:

• Drug free of charge
• 5€ prescription fee, cost of drug over 50 € - 10 € prescription fee

Private prescription:

• No other fees except the cost of the drug

From the age of 20:

• No health insurance benefits except for medical reasons
• Medication costs
• No prescription fee

Social welfare recipients and recipients of unemployment benefit II must bear all contraceptive costs themselves. In some municipalities and cities, however, there are exceptions. Hence it is worth clarifying on the spot whether it is possible to cover the costs after all.

Forgot to take the mini pill?

Make sure you catch up on the pill as soon as possible, even if it means that you have to take two tablets at the same time. Then take the mini pill as usual.

In the next 7 days, additional contraception is absolutely necessary, e.g. with a condom. If you had sexual intercourse in the week before you forgot to take the tablet, there is a risk of pregnancy. The earlier you forget to take the pill in the first week, the greater the risk.

To prevent pregnancy, you can take the Morning after pill within 72 or 120 hours! 

What you can do

Of course, the pill should be taken regularly. Practically, however, this is sometimes not so easy. When a woman takes the "pill" for the first time, it can be difficult to get used to taking it regularly. Even women who have been using the pill for a long time can come across situations where they forget to take it. Stress, illness or forgetting about the pill pack during a short holiday, there are many reasons why the pill can be forgotten. Women are not robots. Here are some frequently asked questions that come forth after one or more forgotten tablets: Are we effectively protected or do we have to use additional contraception, could a pregnancy have occurred, etc.?

Our recommendation should help you to stay effectively protected despite the "forgotten pill". It applies to "pills" which contain 21 identical tablets in combination estrogen/progestin (see package leaflet) and for which a 7-day break is taken after 21 days. If you are taking another pill, e.g. a pill with 3 different tablets, you should consult your doctor or the pro familia-counselling centre nearby as a precaution.

Generally, these two points should be paid attention to:

• Do not stop taking tablets for longer than 7 days.
• In order to build up sufficient contraceptive protection, continuous tablet intake for at least 7 days is required.

Procedure for forgotten pill

pro familia has compiled a recommendation for you on how to proceed in case you forget to take the pill. Our recommendations are based on the recommendations of the Federal Institute for Drug Safety of April 2005.

You forgot one tablet in week 1

Take your medicine as soon as possible, even if it means you have to take two tablets at the same time. Then continue with the intake as usual. In the next 7 days, however, you must also use a barrier method for contraception (e.g. condom). If you had sexual intercourse in the week before you forgot to take the tablet, there is a risk of pregnancy. The earlier you forget to take the pill in the first week, the more likely are the chances for you to get pregnant.

To prevent pregnancy, you can take the “Morning after pill”.

You forgot one tablet in week 2.

Take your medicine as soon as possible, even if it means you have to take two tablets at the same time. Then take the following tablets at the usual time. If you have taken the "pill" regularly on the previous 7 days before the forgotten tablet, the contraceptive effect is guaranteed and you do not have to take any additional contraceptive measures. If you require a particularly high degree of safety, use a barrier method (e.g. condom) within the next 7 days.

You have forgotten one or more tablets one after the other in week 3.

Contraceptive protection is no longer fully guaranteed, if you take the normal break after the end of the pack. The contraceptive effect can be maintained by changing the start of taking the next pack. If you follow one of the two procedures described below, there is no need to use additional contraceptive measures. However, this only holds true, if the tablet was taken correctly on the 7 days before the first forgotten tablet.

If this is not the case, you should proceed according to the instructions. In addition, a barrier method for contraception (e.g. condom) should also be used in the next 7 days. You can choose between these two options:

• 1. Take the remaining tablets from the current pack at the usual time. Do not take any non-prescribed break and start taking the tablets directly from the next pack. Most probably there will not be a withdrawal bleed until you have used up this second pack, but there may be spotting and breakthrough bleeding while taking the tablets from the second pack.

or

• 2. You can also stop taking the current pack immediately and after a break of no more than 7 days (the day on which the first tablet was forgotten must be counted!) you can start taking the next pack straight away. If you want to start taking the new pack on your usual day of the week, you can shorten the break accordingly.

You have forgotten more than one tablet in week 1 or 2.

If you forget to take more than one tablet in week 1 or 2, your contraceptive protection is no longer safe. The more tablets you have forgotten, the more likely it is that you will become pregnant, and the closer it is to the previous non-prescribed break.

To prevent pregnancy, you can take the “Morning after pill”. Until the next round of usual withdrawal bleeding occurs, an additional barrier method for contraception (e.g. Condom) should be used.

If there is no bleeding after using the current pack in the first normal non-prescribed interval and you had sexual intercourse the week before you forgot to take the tablets, you may be pregnant. In this case, you should rule out pregnancy.