Hormonal Methods

Treble-Up: Use 3 Forms of Contraceptive

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Hormonal Methods


To date, there are no male hormone–based methods of birth control, but scientists are working on one. In fact, a male hormonal method is being clinically tested in India. However, it will be some time yet before such methods are available in the U.S.

However, there are many hormone-based options available for women, and they include combination estrogen and progestin pills, progestin-only pills, and the patch, the ring, the injection, the implant and the hormonal IUD. We will cover the hormonal IUD in chapter 8 on IUDs.

Combined hormone methods work by suppressing ovulation and thickening cervical mucus, while progestin-only methods reduce the frequency of ovulation and rely more heavily on changes in cervical mucus and thinning the uterine lining.

The hormone-based methods are reversible, and once you stop using them, you should again be fertile, although with longer lasting methods, it can take longer for fertility to return.

Reasons for Failure

For any method of birth control that requires daily use or use with every instance of sex, the primary cause of failure is user error. Thus, the pill most often fails because the woman forgets to take it or fails to take the pill at about the same time each and every day. The patch, shot and implant are somewhat more effective, because they last longer and present fewer opportunities to forget.

Another cause of failure is that unless started within five days of your period, they take at least a week to become effective.

Other causes of failure include inflammatory bowel disease or other digestive disorders. These can interfere with the absorbance of the pill, making it less effective because it didn’t reach the body. This problem only applies to the pills, which are the only oral forms of hormonal birth control.

Certain medications also interfere with all hormone-based methods of birth control, including certain seizure or migraine meds, St. John’s wort, certain antibiotics (rifampicin and rifabutin) and certain HIV drugs (protease inhibitors [PIs] and nonnucleoside reverse-transcriptase inhibitors [NNRTIs]).

Occasionally there are also manufacturing errors—pills, the ring, the patch, the shot or the implant—are released with insufficient drug or even with just placebo or with some other manufacturing defect. Most recently, millions of Gildess pills were recalled due to a decreased level of drug.[36]

Side Effects

Because hormones do change the body, a prescription is required for their use. These are drugs, and as drugs there may be unintended side effects. In some cases the side effects are severe enough to prevent the use of hormones.

Common side effects include mood changes, spotting between periods, reduced or missed periods, breast tenderness, nausea and vomiting, change in weight, and a change in libido. More serious but rare risks include blood clots. Some cancers are at increased risk, while others are at decreased risk.

However, many women do not experience significant problems, and potential side effects include regular and lighter periods and less premenstrual syndrome (PMS).[37] In fact, the pill is often prescribed to treat awful periods.

It is important to discuss your medical condition with your doctor so that the best regime can be selected for you at your age. For example, smokers over age 35 have increased risks for certain side effects, and some believe that hormone-based methods may not be suitable for the young who have yet to establish a mature functional fertility system. Also, it may be necessary to do a little trial and error to get the best dosage for you. If hormones don’t agree with you, you should consider fertility awareness–based methods, barrier methods, or an IUD.

This description of side effects is by no means comprehensive, but the following web pages will provide more information:



Ultimately though, you should discuss potential side effects with a medical professional as this is a complicated topic and everyone is different.


Some states have written laws that allow pills and patches to be sold over the counter, allowing the pharmacist to write the prescription. Oregon, California, and Washington, DC, have such laws, and similar laws are pending in other states. Another law that makes access easier is one that allows the pharmacist to provide 12 months of pills at once. To see what’s available in your state visit:

https://fivethirtyeight.com/features/some-states-are-making-it-easier-to-get-birth-control/ or https://freethepill.org.

In some states you may not be able to access birth control that requires a prescription without parental permission. Texas is like that. However, Title X clinics will provide teen access, and the nearest Texas clinic can be found at https://www.whfpt.org/find-a-clinic.

In addition, new companies are being launched to provide mail-order prescriptions and delivery. Check out Nurx (which delivers in Texas), Maven or Lemonaid or search “online prescription birth control.”

The Pill

A prescription is needed for the pill in the U.S., and once you have one you can receive mail-order refills. The cost varies up to $50 per month, plus any examination costs. Health insurance will usually pay for pills, and reduced cost or even free pills may be available at clinics.

Whichever pill you take, you have to remember to take it every day at about the same time, which is one of its main disadvantages. There are apps that will remind you to take a pill, but missing pills or taking pills late is a frequent cause of failure (9% failure rate).

Thus, longer acting forms of hormone-based birth control typically have better failure rates because the user has fewer opportunities to forget its application. Don’t forget to use a backup for seven days if you don’t start within five days of your period or if you forget or are late with a pill.


The patch is a thin, beige piece of plastic that looks like a square Band-Aid. It’s a little less than two inches across, and only comes in the one color. It costs about the same as the pill and has the same side effects, but, in addition, the adhesive may also cause irritation. It has a 9% failure rate.

Female Hormone Patch
The patch.[38]

The patch is stuck onto clean skin where it releases hormones that prevent the ovaries from releasing eggs. The hormones also thicken the cervical mucus, helping to block sperm from reaching the egg.

It is applied once a week, every week on the same day for three weeks, and thus it is less likely to be forgotten or late. Then you skip a week.

To use it, pick a patch change day.

You’ll probably get your period during the patchless week, and you may still be bleeding when it’s time to put the patch back on. That’s normal.

If you start the patch within the first five days of your period, you’re protected from pregnancy right away. If you start later, you’ll have to wait seven days before you’re protected and use a backup method.

Carefully consider where you want the patch—it’ll be there for a full week. What will you be wearing? Are there any skin folds there? Can you easily check that it has not fallen off?

Don’t use body lotion, oil, powder, creamy soaps (like Dove or Caress) or makeup on the spot where you put your patch. These can keep the patch from sticking.

Only peel off half of the clear plastic at first, so you’ll have a nonsticky side to hold. Don’t touch the sticky part of the patch with your fingers.

Apply it and press the patch down for a full 10 seconds to get a good, firm stick.

Check your patch every day to make sure it’s sticking right.

When you take a patch off, fold it in half and throw it in the trash.

If you want to skip a period, just skip the week off and add a new patch in the fourth week.

If your patch falls off, but it has been less than 24 hours, you can just reattach the same patch in the same location (as long as it is still sticky). You can also replace it with a new patch.

If your patch has fallen off for more than 24 hours, you MUST apply a new patch (throw out the one that has fallen off). The day that you replace the patch will then become the new day of the week that you change your patch (so if you replace a patch on a Tuesday, then you will change it on Tuesday of the following week).

You should also use a backup birth control method for the first seven days after you have applied a new patch, because it had been more than 24 hours since the previous patch fell off.


The ring is inserted into the vagina to surround the cervix. It is discreet, and a new ring is inserted every three to four weeks. Don’t forget to use a backup for 7 days if you don’t start within 5 days of your period.

Vaginal Ring
Ring (left) fitted into vagina over cervix (right).[39]

If you have health insurance or Medicaid, the ring may be free or it may be available at reduced cost at some clinics. Otherwise, the ring averages around $55 a month.

The ring may have all the side effects of any hormone-based method of birth control. However, the ring uses a lower dose of hormones than other methods, so there may be fewer negative side effects. Your partner typically won’t feel anything, although some do. In clinical studies 90% of partners did not find this to be a problem.

To use it, wash your hands with soap and water. Remove the ring, squish it between your thumb and index finger, and insert it like a tampon. Keep the resealable pouch for disposing of the used ring.

The exact position doesn’t really matter, as long as you’re comfortable.

Once you insert the ring, leave it in for three weeks. Take it out for the fourth week. Then insert a new ring and start the cycle again.

To take the ring out, wash your hands with soap and water. Insert your finger into the vagina and feel for the ring. It can be a bit of a stretch. Hook your finger on the lower edge and pull. Dispose of it by resealing it in the pouch and putting the pouch in the trash.

When the ring is out, you’ll probably get your period. If you’re still bleeding when it’s time to put the ring back in, don’t worry. That’s totally normal.

If you want to skip your period, don’t do the week off. Just insert a new ring at 3 weeks.

The ring sometimes does come out, especially if a tampon catches on it. If this happens, wash it and reinsert it. If it breaks, use a new one.

If the ring has been out of your vagina for more than three continuous hours, use a backup method of birth control for the rest of the month.

Don’t use the ring with the diaphragm as the ring may interfere with the fit of the diaphragm.


The shot is just what it sounds like—a shot that keeps you from getting pregnant—and is called Depo, Depo-Provera, or DMPA (depot medroxyprogesterone acetate). Once you get it, your birth control is covered for three full months—there’s nothing else you have to do. It is reversible, but may take longer since it’s intended to last longer. It has a 6% failure rate.

Female Hormone Shot
The shot.[40]

It costs about $45–$100, but if you average it over the three months it’s not too expensive. It is only available at clinics with a prescription.

The advantage is that it is very discreet—no one can tell if you have taken the shot. The disadvantage is that you have to go to the clinic and get the injection. There is also the minor pain of getting an injection.

Because you only need to remember four times a year to get it, it’s less prone to failure by forgetting. If you miss a shot, however, you increase the risk of getting pregnant. Use a backup method until you get the next shot.

If you start the shot within the first 5 days of your period, you’re protected from pregnancy right away. If you start later, you’ll need to use a backup method for 7 days.

There is one at-home option called SubQ Depo. This is a progestin-only shot that is injected into the skin. Of course, then you have to inject yourself, but some people are able to do this. If you are interested in this option, the prefilled syringe can be purchased at pharmacies with a prescription, and your doctor or nurse can teach you how to do the injection.


The implant (Nexplanon) is a matchstick-size rod that’s inserted under the skin of the upper arm. It is discreet, but may be visible in some women, especially thinner women.

Female Nexplanon Implant
The implant.[41]

The implant releases progestin, preventing the ovaries from releasing eggs, and also thickening cervical mucus, which helps block sperm from reaching the egg. It prevents pregnancy for up to three years and thus is known as a long-acting, reversible contraceptive (LARC), and because it requires no action after insertion, its failure rate is below 1%. As with other hormonal methods, it is effective right away if started within five days of your period; otherwise, use backup for a week.

It’s expensive, at $800–900, but averaged over the length of use, it’s not bad ($300/year or $25/month). It’s also covered by health insurance and Medicaid, and it may be available at lower cost at clinics.

Of course, you need a prescription, and it is inserted into the arm at the clinic. The doctor will numb a small area of your upper arm with a painkiller and then insert the implant under the skin.

You should be able to feel the implant under your skin, and you should check regularly to make sure it stays in place. There may be pain and bruising at the site, and some women report menstrual bleeding for some time until they adjust.

When it’s time to take the implant out, your doctor will numb your arm again, make a tiny cut in your skin, and remove the implant. If you want to continue using the implant, you can get another one at the same time. There may be a charge ($300) to remove the implant as well, or it may be free.

Because there is nothing for you to do, the implant may be the most reliable of the purely hormone-based methods with an actual failure rate of less than 1%. But it’s not perfect, and women sometimes get pregnant while using it.

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