Contraceptive Challenges: Common Birth Control Problems and Fixes

Effectiveness: perfect use vs typical use

The gap between how well a method works in theory and in real life is the biggest contraceptive challenge.

Figures are rounded estimates based on CDC and FDA data. Methods that do not depend on daily or per-act use are far more reliable.

Common problems and solutions

Missed or late pills

• Combined pill, one pill missed (under 48 hours late): take it as soon as you remember, even if it means two pills in one day, and continue as normal. No backup is usually needed.
• Two or more pills missed (48 hours or more): take the most recent missed pill, continue the pack, and use condoms or avoid sex until you have taken 7 active pills in a row. If the missed pills were in the last week of active pills, skip the placebo pills and start the next pack. Consider emergency contraception if you had unprotected sex in the previous 5 days.
• Progestin-only pill (norethindrone): more than 3 hours late counts as missed. Take it, then use backup for 2 days. Newer progestin-only pills (drospirenone) have a 24-hour window.

These follow the CDC's Selected Practice Recommendations. Check your pill's leaflet, because instructions vary.

Solutions: phone alarms, linking the pill to a daily habit, or switching to a method that does not need daily attention, such as an implant, IUD, ring or injection.

Vomiting, diarrhea and medicines that interfere

• Vomiting within 2 to 3 hours of a pill, or severe diarrhea, can stop it being absorbed. Treat it like a missed pill.
• Enzyme-inducing medicines make pills, patches, rings and implants less effective: rifampin, some anti-seizure drugs (carbamazepine, phenytoin, topiramate at higher doses), some HIV medicines and St John's wort. IUDs and the injection are not affected.
• Common antibiotics, apart from rifampin and rifabutin, do not reduce pill effectiveness.

Irregular bleeding and spotting

Spotting is the most common reason people stop hormonal methods. It is especially common in the first 3 months of pills and with implants, injections and hormonal IUDs. Options include waiting, switching pill formulation, or short courses of medicine your clinician can suggest. Persistent or new bleeding should be checked for pregnancy, STIs and cervical problems.

Other side effects

• Nausea and breast tenderness: usually settle within 2 to 3 months. Taking pills at night helps nausea.
• Headaches: common at first. New migraine with aura means estrogen should be stopped.
• Mood changes: some people notice low mood, particularly with progestins. Switching to a non-hormonal method, such as the copper IUD, is an option.
• Weight: most methods do not cause significant weight gain. The injection (DMPA) can cause gain in some users.
• Libido changes: possible with any hormonal method.
• Heavier, crampier periods: common with the copper IUD, especially in the first months.

Medical conditions that limit choices

The CDC's US Medical Eligibility Criteria rate each method's safety for each condition. Estrogen-containing methods (combined pill, patch, ring) are generally not recommended for people who:

• have migraine with aura
• smoke and are 35 or older
• have had a blood clot, stroke or heart attack, or have certain clotting disorders
• have uncontrolled high blood pressure
• are less than 3 to 6 weeks postpartum, depending on breastfeeding and other risks
• have certain liver diseases or breast cancer

Progestin-only and non-hormonal methods are usually safe options. See oral contraceptive thrombosis.

IUD problems

• insertion pain, which can be reduced with local anesthetic
• expulsion, most common in the first year
• strings that cannot be felt (an ultrasound locates the device)
• rarely, perforation of the uterus or infection soon after insertion
• if pregnancy occurs with an IUD, there is a higher chance it is ectopic

Condom problems

Breakage and slipping are usually due to incorrect use, wrong size, oil-based lubricants with latex, or using two condoms together. Use water- or silicone-based lubricant and check the expiry date. Condoms are the only method that also protects against STIs.

Access, cost and privacy

• Under the Affordable Care Act, most US health plans cover FDA-approved contraception without cost-sharing.
• An over-the-counter progestin-only pill is available in the US without a prescription.
• Title X family planning clinics and community health centers provide low-cost, confidential care.
• Telehealth services can prescribe and mail pills, patches and rings.
• Rules on confidential care for teenagers vary by state.

Emergency contraception

Emergency contraception prevents or delays ovulation. It does not end an existing pregnancy. Take a pregnancy test if your period is more than 7 days late afterward.

Choosing a method

Questions to discuss with a clinician:

• How important is it to avoid pregnancy right now?
• Do you want a method you can forget about, or one you control day to day?
• Do you want lighter periods, or to avoid hormones?
• Do you have migraines, high blood pressure, a clot history, or take other medicines?
• Do you need STI protection?
• When might you want to become pregnant?

Frequently asked questions

What are the most common birth control problems?

The most common problems are missed or late pills, irregular bleeding and spotting, side effects such as headaches, nausea and mood changes, drug interactions, condoms breaking or slipping, and difficulty accessing or affording the preferred method.

What should I do if I miss a birth control pill?

For a combined pill, take the missed pill as soon as you remember and continue as normal. If you missed 2 or more, use condoms until you have taken 7 active pills in a row and consider emergency contraception if you had sex in the previous 5 days. Check your pack's instructions.

Which birth control has the fewest side effects?

There is no single answer, because people react differently. The copper IUD has no hormones but can make periods heavier. Hormonal IUDs release very low hormone levels and often lighten periods. A clinician can help match a method to your health and preferences.

Why am I bleeding on birth control?

Spotting between periods is common in the first 3 months of most hormonal methods and with implants and injections. Missed pills, interacting medicines, smoking, pregnancy, infections and cervical problems can also cause bleeding. See a clinician if it lasts beyond 3 months or is new after a long time on the method.

How effective is emergency contraception?

The copper IUD prevents more than 99% of pregnancies when inserted within 5 days. Ulipristal works up to 5 days and is more effective than levonorgestrel, which works best within 72 hours. Pills are less effective the longer you wait and may be less effective at higher body weight.