The Pill, Patch and Ring

a graphic of the pill, patch and ringThe birth control pill, patch and ring are medications taken to prevent pregnancy, regulate menstrual cycles or help with menstrual pain and heavy bleeding. The pill, patch and ring are together known as “combined-hormonal contraceptive methods” because they  contain two hormones - estrogen and progestin
*Some birth control pills contain only one hormone - progestin. These are sometimes called “mini-pills”. Progestin-only pills are good for those who cannot (or prefer not to) use estrogen. For more info on mini-pills, see American Academy of Family Physician's information.

The pill, patch and ring are very reliable birth control methods. If used correctly – that is, the pill taken every day at the same time each day, the patch and ring changed at appropriate intervals - fewer than 1 in 100 users will become pregnant (0.3%). If not always used correctly, 9 of 100 combined hormonal contraceptive users will become pregnant (9%). 

There are many combined hormone contraceptive options available today, and while each one provides the same effectiveness against pregnancy when used correctly, there are variations between brands in the appearance, composition, and directions for use. Be sure to ask your healthcare provider or pharmacist for instructions regarding how to take your birth control.

COMBINED HORMONAL CONTRACEPTIVE METHODS DO NOT PREVENT SEXUALLY TRANSMITTED INFECTIONS. USE A CONDOM WITH EVERY ACT OF INTERCOURSE TO REDUCE YOUR RISK OF ACQUIRING SEXUALLY TRANSMITTED INFECTIONS.

BEFORE STARTING CONTRACEPTION

Be sure that you have informed your health care provider if you:

  • Take any medications, herbal products, or dietary supplements
  • Smoke  
  • Have any history of migraine headaches, hepatitis, breast lumps or nodules, diseases involving blood clots, tumors of the ovaries, diabetes, high blood pressure, heart attacks, cancer of the female organs, active gallbladder disease, inflammatory bowel disease, lupus, rheumatoid arthritis, blood clots in your family or blood clotting factor mutations, bariatric surgery, or solid organ transplant 

People with certain health conditions should not use combined hormonal contraception (pill, patch or ring). Some people will need closer monitoring while on the pill, patch or ring to reduce the risk of negative health effects. Your healthcare provider will help you weigh your particular risks relative to taking contraception. Smoking while on combined hormonal contraception significantly increases the risk of certain side effects (blood clots, stroke, heart attack), especially if you are over 35 years old. Ask your health care provider for help with quitting smoking to decrease your risk.

HOW DOES THE PILL, PATCH & RING WORK?

These contraception methods prevent pregnancy mainly by suppressing ovulation (the release of the egg from the ovary) and by thickening cervical mucus, therefore hampering the transport of sperm and preventing fertilization.  

WHAT ARE SOME DISADVANTAGES OF THE PILL, PATCH & RING?

  • STI risk: These contraception methods do not protect against sexually transmitted infections (STIs). Condoms do help protect against STIs. Use a condom with every act of sexual intercourse to reduce your risk of acquiring STIs.
  • Timing Specificity: Birth control pills must be taken every day at the same time for maximum effectiveness. The patch and ring need to be changed at the correct intervals as well. 
  • Provider visits: A prescription is needed to obtain birth control pills, patches, or rings. This requires an annual visit to a health care provider.
  • Side effects: Some side effects may occur while using these contraception methods. The most common side effects include bleeding between periods, breast tenderness, headaches and nausea. These side effects typically only last for the first few months. Persistent minor side effects might be eliminated by changing the type of contraceptive you are using. If you are experiencing problems, contact a health care provider BEFORE you stop using the pill, patch or ring. 
  • Serious side effects: These are rarely seen because of the lower doses of hormones used in pills today compared to many years ago. Serious side effects that are possible but not likely include migraine headache, elevated blood pressure, blood clots (in the rare case these occur, they tend to happen in the leg, arm, or lung. Risk is highest during the first 6 months after starting the pill for the first time or after taking a 2 month or longer break from taking the pill), nonmalignant liver tumors, gall bladder disease, heart attack, or stroke.
    • Warning signs of serious side effects from birth control pills are listed below. Immediately contact a health care provider if you experience any of the early warning signs. An easy way to remember these early warning signs of a more serious medical condition is to note that the first letter of each symptom spells out ACHES.
      •  Abdominal pain (severe), yellow skin or eyes
      • Chest pain (severe)
      • Headaches (severe)
      • Eye problems (vision loss, vision disturbances)
      • Severe leg or arm pain or swelling (in the calf, thigh or upper arm)

WHAT IS HAPPENING THE LAST WEEK OF THE MONTH WITH THESE METHODS?

These options tend to have 21 days of active hormones. The last 7 days of a month tend to have no hormones, so pill packs contain inactive “reminder” pills. The patch and ring either have 7 days without use, or uses can continue using their method through a full 28 days. After 28 days, a new month of the active hormonal method begins. You are protected from pregnancy during that last week. The purpose of inactive “reminder” pills is to continue the habit of taking a pill each day. Some people choose not to take the inactive pills. Do not stop using your contraceptive method during active weeks  unless directed by your health care provider.
You should expect your menstrual bleeding to occur during the week when you are not getting hormones. Even on extended regimens where users continue their hormonal method through day 28, light bleeding may occur during those last 7 days of use. Your bleeding may or may not end before you start your new month of contraception. Start your month immediately after day 28, even if you are still bleeding.

HOW DO I START USING THE PILL, PATCH or RING?  

There are three ways you can start using the Pill, Patch or Ring.

  • Quick Start (recommended): Start your contraception – take your first pill, place a patch, or insert a ring - any day of your menstrual cycle if you are reasonably sure you are not currently pregnant. Use a backup method such as condoms for the first 7 days of use.
  • Sunday Start: Start your first packet of pills, place a patch or insert a ring on the first Sunday after your menstrual flow begins. Use a backup method such as condoms for the first 7 days of use if it has been more than 5 days since menstrual bleeding.
  • Day 1 start: Start your first packet of pills, place a patch, or insert a ring on the first day of your menstrual flow. You are protected against pregnancy as soon as you start your contraceptive method.

US Department of Health and Human Services/Centers for Disease Control and Prevention, U.S. Selected Practice Recommendations for Contraceptive Use, 2016, MMWR/July 29,2016/Vol. 65/No.4

HOW SOON WILL I BE PROTECTED AGAINST PREGNANCY AFTER STARTING THE PILL, PATCH or RING?  

When you begin your first pack of pills, place your patch or insert your ring, you should use a backup method of birth control, such as condoms, for the first 7 days of the pack if you use the Quick Start. If your pill, patch or ring is started 5 days or more since menstrual bleeding started, then you need to use additional contraception such as a condom or abstain for 7 days. If you begin taking your pill, patch or ring on the first day of your menstrual flow, you do not need to use a backup method for the first 7 days.

WHEN SHOULD I TAKE MY PILL, PLACE MY PATCH, or INSERT MY RING?  

Take your pill at approximately the same time each day. The effectiveness of the pill depends upon your consistency. 
Change your patch the same time each week.
Place a ring in the vagina for 3 weeks, take it out for 1 week then replace with new ring. 
Remembering these schedules can be difficult. Many users find it helpful to set an alarm on your phone, or use a reminder service like bedsider.org/reminders.

IF I DON’T WANT TO HAVE MY WITHDRAWAL BLEEDING (“PERIOD”) AT A PARTICULAR TIME, CAN I JUST SKIP THE INACTIVE PILLS or WEEK WITHOUT THE PATCH or RING?

One advantage of combined hormonal contraceptive methods  is the ability to both predict and manipulate your cycle. Consult with your health care provider before taking your method in ways other than as directed. If you simply use two months of your method and skip the inactive week, you may experience irregular bleeding. For information about how to avoid your withdrawal bleeding on a particular date, consult your health care provider with as much advance timing as possible or look at bedsider.org’s info on skipping a period.
Birth control may be used safely for extended periods of time. Consult your health care provider if you have questions about extended regimens. See bedsider.org’s information on extended use of hormonal contraception. 

OOPS! WHAT IF I MISS A PILL?

Mistakes happen with the pill, patch and ring. If you’re concerned you might be pregnant, taking an over-the-counter pregnancy test is a reasonable option. If it’s negative, continue using your contraceptive option and use a backup method for 7 days.

If you are less than 24 hours late taking your pill, take it now and take your next pill at the time you usually would. No further action is needed.
If you are more than 24 hours late, take your missed pill now and any other pill you are supposed to take today. Consider taking emergency contraception (with the exception of Ulipristal) if you have had penile-vaginal sex in the last 5 days without additional protection such as a condom. Use a backup method such as abstinence or a condom with every act of penile-vaginal sex until you have taken 7 active pills in a row. Finish taking all other pills in your pack on time. 
If you have lost a pill, follow the appropriate instructions above, then take the next pill in the pack and continue to take the remaining pills every day. You will begin your new packet of pills one day sooner.
If you vomit within 1-2 hours after taking an active pill, consider it a missed pill and refer to the previously provided instructions.
If you have severe diarrhea (>3 loose stools in 24 hours), consider it a missed pill and refer to the previously provided instructions.

OOPS! WHAT IF I MISS AN INACTIVE PILL?  

If you are using a 28-day pack of pills and you forget any of the 7 inactive pills (which have no hormones) in week 4, discard the pills you missed and keep taking one pill each day until the pack is empty. You do not need a backup method of birth control.

OOPS! WHAT IF I AM LATE REPLACING THE PATCH OR THE PATCH BECOMES DETACHED?

Mistakes happen with the pill, patch and ring. If you’re concerned you might be pregnant, taking an over-the-counter pregnancy test is a reasonable option. If it’s negative, continue using your contraceptive option and use a backup method for 7 days.

If you are less than 48 hours late to replace or the detachment has been going on for less than 48 hours, then apply a new patch as soon as possible. Keep the same patch change day. No additional protections needed. 
If you are more than 48 hours late to replace or the detachment has been going on for more than 48 hours then apply a new patch as soon as possible. Keep the same patch change day. Consider taking emergency contraception (with the exception of Ulipristal) if you have had penile-vaginal sex in the last 5 days without additional protection such as a condom. Use a backup method such as abstinence or a condom with every act of penile-vaginal sex until you have had the patch on for 7 consecutive days. 

OOPS! WHAT IF THE RING FALLS OUT OR I FORGOT TO REPLACE THE RING?

If the ring accidently falls out - for example, while removing a tampon, during sex, or while straining during a bowel movement - you can put it back in the vagina after rinsing with water. Reinsert as soon as possible. 
If the ring is left outside the vagina for less than 3 hours the effectiveness of the ring is not reduced.
If the ring is out of the vagina for more than 3 hours, the effectiveness may be impacted. During weeks 1 and 2, reinsert the ring as soon as possible. During week 3, discard the ring and insert a new ring. If you leave the ring in for longer than 4 weeks, remove the ring, and insert a new ring as soon as you remember. With any of these situations - consider taking emergency contraception (with the exception of Ulipristal) if you have had penile-vaginal sex in the last 5 days without additional protection such as a condom. Use a backup method such as abstinence or a condom with every act of penile-vaginal sex until you have had the ring in for 7 days.

WHAT IS EMERGENCY CONTRACEPTION? WHEN MIGHT I NEED IT?

Emergency contraception (Plan B,® “the morning-after pill”) can be used if you have an “oops” with your contraception. It is available over-the-counter. Take it as soon as possible after penile-vaginal sex without effective contraception. It is most effective when used within 5 days. Emergency contraception is meant for emergency use only and is not an effective method of birth control for routine use. The other type of emergency contraception called Ulipristal is not recommended for people who are also using the pill, patch or ring without consulting with a provider or pharmacist for further details.

WHAT DO I DO IF I MISS A PERIOD?  

If you used your method correctly and skip a period, it is unlikely that you are pregnant. It is common for hormonal contraceptive users to occasionally miss periods and for their periods to be very light and last only one day or less. If you skip a period and are concerned about your risk of pregnancy, contact a health care provider and ask for a pregnancy test. Even if you did not have a period, you should start a new package of pills, patch or ring at the regularly scheduled time. If you skip two periods in a row, contact your health care provider.

WHEN SHOULD I BE SEEN AGAIN BY MY HEALTH CARE PROVIDER?

See your health care provider once a year for a wellness visit. A wellness visit is necessary to renew your prescription for contraception. Testing for sexually transmitted infections, especially for people 25 years or younger, is also recommended annually. A Pap smear is recommended every 3 years if you are 21 or older. Make an appointment with your provider before you run out of your pills, patches, or rings - do not wait until the last minute to make your appointment. If you have problems at any time, contact your health care provider.

WHAT SHOULD I DO IF I RUN OUT OF MY PILLS, PATCHES or RINGS?  

First, make sure you have enough pills, patches or rings/prescription refills to last through the holidays, semester breaks, and summer recess before you leave campus. If you miscalculate or lose your contraception, contact your pharmacy immediately. If you cannot get more of your hormonal contraception, use a backup method of birth control such as condoms. If your backup method fails, consider taking emergency contraception. 

SHOULD I TELL OTHER MEDICAL PROVIDERS THAT I AM USING THE PILL, PATCH or RING? 

Yes. Hormonal contraception is medication. Make sure that all of your health care providers (including your pharmacists) know about all of the medications you are taking, including the pill, patch or ring.

DO I NEED TO TAKE A REST FROM HORMONAL CONTRACEPTION? 

Current data indicate that there is no need to stop hormonal contraception at intervals. You should not stop using the pill, patch or ring without using alternative contraception if you want to avoid pregnancy. Many pill, patch or ring users become pregnant soon after they stop using their contraceptive method.

WHAT DO I DO IF I DECIDE I WANT TO GET PREGNANT?  

If you decide you want to get pregnant, call 919-966-2281 to make an appointment for preconception counseling with a provider in Gynecology before you stop taking contraception. This counseling will provide you with important information before conception. For example, you should take 800 mcg of folic acid daily, preferably for at least three months before you stop birth control. 
There is no evidence that the pill, patch or ring decreases subsequent fertility, and the return to fertility is usually rapid. Usually pill, patch and ring users return to the pattern of menstruation that was normal for them before they took contraception. Reports have confirmed that inadvertent contraception use during early pregnancy does not increase the risk of fetal malformations.

WHAT IF I SWITCH FROM ONE KIND OF HORMONAL CONTRACEPTIVE TO ANOTHER? 

When switching from one kind of pill to a different pill, it is not necessary to use a back-up method of contraception as long as you begin the new pill pack at or before the time you would have started a new pack of your current pill. However, when switching from the pill to other hormonal methods like the ring, patch or shot, timing is critical. Ask your health care provider if or for how long you might have to use a back-up method of birth control, such as condoms, if you switch from the pill to a different hormonal method.

ARE THERE ANY DRUG INTERACTIONS WITH THE PILL, PATCH or RING?  

Yes, some medications – both prescription and over the counter – as well as some supplements and herbals may decrease the effectiveness of combined hormonal contraception. Use of anticonvulsants including phenytoin, carbamazepine, barbiturates, primidone, topirmate, oxycarbazepine may decrease the effectiveness of the contraceptive and it recommended to consult with your health care provider to find an alternative. The pill, patch and ring may also change the effects of other medications. Talk with your healthcare provider to determine if you need to use a backup method or consider a new type of contraception whenever you begin taking prescription or over the counter medications including supplements or herbals. Additionally, the patient package insert for your contraception includes specific medication warnings. 

WHAT IF I HAVE MORE QUESTIONS? 

If you have any questions or concerns regarding the pill or other birth control methods, consult your health care provider. 

If you're a UNC student, you can also visit a Sexual Health and Relationship Educator (SHARE) in Student Wellness. Any health care provider at Campus Health can help you with your birth control questions and needs. If you would prefer a Gynecology provider, specify your request when making an appointment.
You can make a SHARE appointment by calling 919-962-9355 or emailing LetsTalkAboutIt@unc.edu. Learn more at studentwellness.unc.edu/SHARE
Several websites offer more information about the pill including bedsider.org or arhp.org/methodmatch