It’s the summer of 1960, and in the United States a new medication enters the market—what we now know as “the pill.” Just a year later, the contraceptive also spreads to the German market—initially prescribed as a remedy for menstrual problems, and only for married women* with children. Its effectiveness as a contraceptive was mentioned only in the package insert at the time. But it was known, and in the following years it sparked a sexual revolution, allegedly leading to a decline in birth rates that became known as the “pill dip.” Above all, however, the pill meant one thing: women* could approach family planning on their own terms.

What types of pills are there?

The pill has been continually developed since those early days. Today, it remains one of the most frequently prescribed contraceptives. According to an AOK analysis, in 2020, 35 percent of women* up to age 20 with statutory health insurance were prescribed the pill. The first-generation pill—the one introduced in the summer of 1960—was a combination preparation of estrogen and progestin. Today, there are second-, third-, and fourth-generation pills. In addition, the classic combination pill is now available as a lower-dose “micro pill.” Another option is the “mini pill.” Below is an overview of the pill types currently available.

Combination pill / Micro pill

The first pill to come on the market in 1960 was a combination pill. Even today, most prescribed pills are based on the hormone combination of progestin and estrogen, though the estrogen dose is now significantly lower. If the dose is under 0.05 milligrams, it is called a micro pill.

How does the micro pill work?

The hormones in the micro pill work in three ways to prevent pregnancy. They inhibit egg maturation and ovulation, so there is no egg cell that can be fertilized. They thicken cervical mucus, blocking sperm from entering and they prevent the uterine lining from building up, so a fertilized egg cannot implant.

Triphasic and quadriphasic pills: The triphasic pill goes one step further and contains different concentrations of progestins in three phases. As with the biphasic pill, users first take only estrogen; in the second week, progestin is added; and in the third week, the progestin concentration is increased while the estrogen is reduced.

The newest version is the quadriphasic pill, with the active ingredients dienogest (a progestin) and estradiol (an estrogen). It follows a similar scheme to the triphasic pill but also includes placebo pills at the end of the cycle to avoid interrupting the intake schedule. For both phased models, as with the biphasic pill, it is essential to follow the correct order.

You may have already heard of different generations of pills. Today there are four generations, which differ in their composition.

The first-generation pill contained the synthetic ethinylestradiol and the progestin norethisterone, which promised a relatively low risk of thrombosis. However, side effects included hair loss, facial hair growth, and acne.

In the second generation, levonorgestrel was used, but with similar side effects. These could include nausea, vomiting, headaches, depressed mood, or loss of libido.

The newer generations—the third and fourth—carry a higher risk of blood clots in the leg veins. At the same time, however, they are known for improving skin appearance.

What are the advantages of the combination pill?

Women* who take a combination pill do not need to worry about unintended pregnancy when used correctly. The Pearl Index is very low: between 0.1 and 0.9 (this means that out of 1,000 women* who use the combination pill for one year, an average of 1 to 9 still become pregnant). In addition, bleeding is usually lighter and shorter than in a natural cycle. Because the combination pill suppresses the buildup of the uterine lining, it can ease endometriosis-related symptoms, though it is not officially approved for this purpose.

What are the disadvantages of the combination pill?

The risk of thrombosis is demonstrably increased when taking a combination pill. This means that menstruating people with other risk factors—such as smoking, chronic illness, or a family history of thrombosis—should switch to other alternatives.

Other known side effects include nausea, dizziness, mood swings, depressed mood, headaches, loss of libido, or breast tenderness.

If you start taking the combination pill on the first day of your cycle (the first day of menstruation), protection is immediate. If you start between the second and fifth day of menstruation, you should use additional contraception, such as condoms, for the first seven days. Only after that, the hormones will protect you reliably.

Mini pill

Unlike the combination pill, mini pills do not contain estrogens. They contain as active ingredient either the progestin hormone levonorgestrel or desogestrel.

How does the mini pill work?

The hormones cause the mucus in the cervix to become so thick that sperm cannot pass into the uterus. In addition, the uterine lining builds up only insufficiently, which makes it more difficult for a fertilized egg to implant. Mini pills with the hormone desogestrel also prevent ovulation.

Mini pills are taken without a break. This means that instead of interrupting intake for a few days, menstruating people start directly with the next pack once the previous one is finished.

What are the advantages of the mini pill?

The mini pill is also a reliable contraceptive when taken correctly. The Pearl Index is 0.5, but because of frequent intake errors it is also rated at 3.0–4.0. The mini pill is recommended for women* with an increased risk of thrombosis or for those who experienced strong side effects when taking the combination pill. In addition, women* who have given birth or who are breastfeeding can take the mini pill, since progestins have no effect on the amount of breast milk. Many women* report having no or only very light bleeding while taking the mini pill, which means that menstrual pain hardly occurs or not at all.

What are the disadvantages of the mini pill?

The progestins it contains can trigger mood swings or even depression. Mini pills with levonorgestrel must also be taken as close as possible to the same time every day to maintain contraceptive protection. This type of pill therefore requires a high level of discipline. Preparations with desogestrel allow a time window of twelve hours.

When am I protected?

Contraceptive protection exists from the first day of intake, provided that this is the first day of the cycle, i.e. the first day of menstruation. If you start only on the second to fifth day of the cycle, you must use additional contraception for seven days until protection is established.

Du hast völlig recht 👍 – im deutschen Original standen diese Passagen ebenfalls als Fließtext und nicht als Listen. Ich habe die Stellen (z. B. bei der Pille danach und am Ende bei „Es muss nicht immer die Pille sein“) unnötig in Bullet Points aufgelöst.

Special case: The morning-after pill

The morning-after pill is not a contraceptive method but is only used in cases where contraception has failed—for example, if a condom breaks during sex or if contraception was forgotten. The morning-after pill should be taken as quickly as possible and is available without prescription in pharmacies. But attention: The morning-after pill is a strong hormonal intervention and should only really be taken in exceptional cases. It is not suitable as a regular contraceptive.

If it is taken before ovulation, it will with high probability prevent pregnancy, since it suppresses or delays ovulation and thus prevents sperm and egg from meeting. The morning-after pill is most effective within twelve hours after unprotected intercourse, as its effect decreases over time. Preparations containing the active ingredient levonorgestrel can be taken up to 72 hours after unprotected sex. If the morning-after pill contains ulipristal acetate, it can be taken up to a maximum of 120 hours after contraceptive failure.

With each passing day, however, the likelihood increases that ovulation is approaching. Levonorgestrel preparations work if taken up to two days before ovulation. Pills with ulipristal acetate are effective even the day before ovulation. Shortly before or once ovulation has already occurred, both preparations are ineffective.

Which pill is right for me?

If you decide to use the pill as contraception, you should work with your gynecologist to determine which of the options presented is best for you. Factors such as pre-existing conditions (your own or within the family) or how regular your daily routine is play an important role. It doesn’t always have to be the pill

Although the pill is still popular and often prescribed, figures from recent years show that prescriptions are decreasing and women* are looking into other options for contraception. Contraceptives such as the vaginal ring and the contraceptive patch belong, like the micro pill, to the combined hormonal methods. Implants are also part of the so-called progestin methods, which contain only progestin and no estrogen.

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