›Must read before starting medication
Important Safety Information about hormonal birth control:
By proceeding with the asynchronous visit, you acknowledge that:
- You consent to treatment as described in the ‘Permission to Treat’ section of our Terms of Use
- You reviewed and answered the screening and booking flow questions truthfully and thoroughly
- You have read and understood the information on how your prescribed birth control method works, and the possible benefits, risks, and alternatives
- You agree to follow the usage instructions and will seek medical care if you experience serious side effects or have concerns.
- You have been informed of alternative contraceptive options and understand that no method (except abstinence) is 100% effective, and that only condoms can provide significant protection against sexually transmitted infections.
- Please note: We do not prescribe any abortion medications.
Disclaimer: PlushCare's asynchronous visit service for birth control and the information provided here are not intended for the prescription of emergency contraception (such as Ella or Plan B) because it may take up to 48 hours to obtain your birth control prescription. If you have had unprotected intercourse within the last 120 hours (5 days) and need emergency contraception such as Ella or Plan B, we recommend scheduling a video visit with one of our PlushCare physicians instead.
Introduction: What is hormonal birth control?
Hormonal birth control is any pill, injection, device, or treatment that uses hormones to prevent pregnancy. There are a few different kinds of hormonal birth control. Some contain 2 hormones estrogen and progestin, and others contain only progestin.
Overview of Birth Control Methods
While no birth control works 100 percent perfectly all the time, hormonal methods work very well to prevent pregnancy. The methods differ in how easy they are to use and their side effects:
- Pills – If you choose to take birth control pills, you will need to take a pill every day. Skipping pills can increase the chance of getting pregnant. Birth control pill packets usually include 4 to 7 days of hormone-free pills each month. It is during these hormone-free days that you get your period. If you prefer not to get a period, you can skip the hormone-free pills and take a hormone pill every day instead. This is called "continuous dosing." Most birth control pills contain estrogen and progestin, but some contain only progestin.
- Skin patches – Two different patches are available (brand names: Xulane, Twirla). You can wear the patch on your shoulder, back, belly, or hip. One of them (Xulane) can also be worn on the upper arm. The patch must be changed once a week, and you put it in a new place each time. You typically wear a new patch each week for three weeks and then leave the patch off during week 4. Week 4 is when you have your period. Skin patches for birth control contain both estrogen and progestin.
- Vaginal rings – This is a flexible ring you put in your vagina (brand names: Annovera, EluRyng, NuvaRing). It can stay in place for three weeks at a time.The ring releases hormones in the vagina, and it does not need to be removed when you have sex. You will need to make sure the ring is in place after sex.
- If you choose, you can continue using a ring for longer than three weeks. If you do this, you will not have a regular period, although you might have some light bleeding or "spotting." Vaginal rings for birth control contain both estrogen and progestin. Annovera is the only brand where you use the same ring all year. The other rings need to be changed monthly.
These are some additional contraception options that are not available through the PlushCare asynchronous visit:
- Injections – If you use hormone injections, you will get a shot in the arm or butt every three months. Injections for birth control (brand name: Depo-Provera) contain only progestin. With perfect use, fewer than 0.3 out of 100 women will become pregnant in a year; with typical use, about 3 out of 100 women will become pregnant per year
- Implants – A birth control implant is a tiny rod that releases hormones in the arm. It must be implanted by a doctor or nurse and can stay in the arm for up to 3 years. Implants for birth control (brand name: Nexplanon) contain only progestin. Nexplanon is over 99% effective at preventing pregnancy, with fewer than 1 pregnancy per 100 women per year
- Hormone-releasing IUD – IUD stands for "intrauterine device." This is a device that is placed inside the uterus to prevent pregnancy. Some IUDs work by releasing hormones into the body (brand names: Kyleena, Liletta, Mirena, Skyla). Depending on which hormone-releasing IUD you get and your age, it can stay in place for 3 to 8 years. The hormone-releasing IUDs contain the hormone levonorgestrel, which is a progestin. These levonorgestrel-releasing IUDs are more than 99% effective at preventing pregnancy, with typical-use failure rates under 1% per year
- There are non-hormonal options for birth control that are only available with a prescription. These include the Copper IUD (brand name Paraguard) and Phexxi, a non-hormonal contraceptive film that is used each time you have sex. Paraguard is proven over 99% effective (fewer than 1 pregnancy per 100 women per year). Phexxi, when used perfectly, is about 93% effective; with typical use it prevents pregnancy in about 86 out of 100 women per year. These methods are also not available from our asynchronous visit platform.
Most other non-hormonal methods are either available over the counter or are activity-based. These can be used alone or combined with hormonal birth control for additional efficacy. Some of these are female or male condoms, spermicides, fertility awareness method, lactational amenorrhea, and coitus interruptus or withdrawal/ “pulling out”.
Hormonal birth control is a safe and reliable way to prevent pregnancy for most people but it does not protect you from infections that spread through sex (called STIs or "sexually transmitted infections " or "sexually transmitted diseases"). Using a condom correctly and consistently each time you have sex can help prevent STIs.
Is hormonal birth control safe for everyone?
Some people should not use estrogen-containing hormonal birth control. This includes those who:
- Are age 35 or older and smoke cigarettes – These increase your risk for heart attacks and strokes.
- Could possibly be pregnant – Before prescribing hormonal birth control, your doctor or nurse will ask questions to make sure there you are not pregnant. You might need to take a pregnancy test to confirm this.
- Have had a history of blood clot, heart attack or a stroke
- Have a condition that increases risks of blood clots. Some conditions are permanent like inherited clotting disorders and others are temporary (i.e. if you will be immobilized for a long period because of surgery)
- Are being treated for breast cancer or have had breast cancer before
- Have irregular or very heavy periods – If you have this problem, you should have it checked out before starting hormonal birth control.
- Have some types of liver disease – Hormonal birth control can make some types of liver disease worse.
- Have certain types of kidney disease
- Have some types of heart disease
- Solid organ transplant patients
- Have adrenal insufficiency
- Have sickle cell disease
- Get the type of migraine headaches that cause vision or hearing problems
- Have symptomatic or active gallbladder disease
- Have had diabetes for over 20 years or have complications from diabetes, such as kidney or eye disease
- Have inflammatory bowel disease such as Crohn's or Ulcerative Colitis
If you have high blood pressure, you may still be able to use hormonal birth control. But your blood pressure needs to be well controlled and regularly checked.
Some patients that can use estrogen-containing birth control methods but it may be safer to use a patch or ring because of absorption issues like those who have had gastric bypass surgery.
If you aren’t sure if you have a condition that makes you not able to take certain birth control methods or have any questions about if these conditions apply to you, you can exit the asynchronous pathway and book an appointment to speak with one of our physicians.
Many people who can't take estrogen-containing hormonal birth control can take other kinds of hormonal birth control that contain only progestin. Or they can use methods that do not contain hormones.
What if I take medicines besides birth control?
Some medicines can affect how well hormonal birth control works. Please make sure to share all of the medications that you take so that your physician can make an informed decision on which type of birth control is safest for you to take. Some medications that may interact with birth control include but are not limited to:
- Some medicines used to prevent seizures (called "anticonvulsants")
- Certain antibiotics used to treat tuberculosis (rifampin and rifabutin)
- St. John's Wort (an herbal medicine for depression)
What if I forget to use my hormonal birth control?
If you have sex and forgot to use your birth control, you can take emergency contraception to reduce your risk of pregnancy. Some forms of emergency contraception require a prescription, but others you can buy in a pharmacy. If you need to use emergency contraception, it should be done as soon as possible after sex.
Information on each birth control options:
Below is a guide on the key components of each type of birth control method available as a prescription through PlushCare's asynchronous visits. They cover the mechanism of action, effectiveness, benefits, most common potential risks and side effects, contraindications and alternatives:
1. Combined Oral Contraceptives (COCs)
Mechanism of Action
COCs contain both estrogen and progestin. They prevent pregnancy primarily by suppressing ovulation, thickening cervical mucus (blocking sperm), and thinning the endometrial lining (which could discourage implantation but also has the added benefit of potentially lighter periods).
Initiation & Backup Contraception: Here are the different ways on when to start taking combined oral contraceptives, as well as whether you may need back-up contraception depending on when you start the birth control. Backup contraception—most commonly condoms—is recommended whenever you’re initiating or restarting a hormonal method to ensure you’re protected during the “window” before the hormones have reached full effectiveness.
- Day-1 Start (first day of menses): Begin your first pill on Day 1 of your period. No backup contraception is needed.
- Sunday Start (“Quick Start”): Begin on the first Sunday after your period begins. Use backup condoms for the first 7 days of active pills.
- Quick-Start Anytime: You may start the pill on any day for convenience. Use backup condoms for 7 days.
- Missed Period on First Pack: If you start mid-cycle and haven’t had a period in the past month, you may wish to confirm you are not pregnant before starting and also use backup until you’ve taken 7 consecutive active pills and confirm you’re not pregnant.
Effectiveness
- Perfect‐use failure rate: ~0.3% per year
- Typical‐use failure rate: ~7% per year
Key Benefits
- Highly effective when taken correctly
- Regulates menstrual cycles and reduces dysmenorrhea (painful periods)
- Improves acne and reduces risk of ovarian/endometrial cancer
- May decrease menstrual blood loss and anemia risk
Potential Risks & Side Effects
- Thromboembolism: Slightly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), especially in smokers over age 35 or those with clotting disorders
- Cardiovascular: Elevated blood pressure, rare risk of heart attack or stroke in high-risk individuals
- Other: Nausea, breast tenderness, headaches, breakthrough bleeding, mood changes
Usage Considerations & Adherence
- Take one pill at the same time every day.
- Missing a pill by >24 hours increases pregnancy risk
- Certain antibiotics, anticonvulsants, and supplements may reduce effectiveness.
Contraindications & When to Seek Care
- History of thromboembolic disorders, uncontrolled hypertension, migraine with aura, estrogen-dependent tumors, or smokers ≥35 years.
- Seek immediate care for chest pain, sudden shortness of breath, severe headache, vision changes, or leg swelling.
2. Progestin-Only Pills (POPs, “Mini-Pills”)
Mechanism of Action
Contain only a progestin. Primarily work by thickening cervical mucus and altering the endometrium; ovulation may still occur in some cycles.
Initiation & Backup Contraception: Here are the different ways on when to start taking progestin only pills, as well as whether you may need back-up contraception depending on when you start the birth control. Backup contraception—most commonly condoms—is recommended whenever you’re initiating or restarting a hormonal method to ensure you’re protected during the “window” before the hormones have reached full effectiveness.
- Any Day Start: You may begin a POP on any calendar day. Use backup condoms for the first 48 hours (2 days) of continuous use.
- Postpartum/Breastfeeding: Can start immediately postpartum (even within 6 weeks) with no backup needed if started within 21 days of delivery; otherwise use backup for 48 hours.
- Missed Dose Protocol: If you’re >3 hours late (or >12 hours for drospirenone pills), use backup condoms for the next 48 hours after you restart.
Effectiveness
- Perfect‐use failure rate: ~0.3% per year
- Typical-use failure rate: ~9% per year
Key Benefits
- No estrogen—safer for most with estrogen contraindications
- Can be used while breastfeeding (no impact on milk supply)
Potential Risks & Side Effects
- Irregular bleeding or spotting, especially in the first 3–6 months
- Breast tenderness, headaches, mood swings
- Slight weight changes
Usage Considerations & Adherence
- Must be taken at exactly the same time every day (±3 hours); even a few hours’ delay increases pregnancy risk
- No “pill-free” interval—daily dosing continuous
Contraindications & When to Seek Care
- Active liver disease or tumors, unexplained vaginal bleeding, breast cancer
- Report any signs of blood clots, though risk is lower than with estrogen
3. Transdermal Patch
Mechanism of Action
Similar to COC but delivers both estrogen and progestin through the skin: suppresses ovulation, thickens cervical mucus, thins endometrium.
Initiation & Backup Contraception
Here are the different ways on when to start using transdermal birth control patches, as well as whether you may need back-up contraception depending on when you start the birth control. Backup contraception—most commonly condoms—is recommended whenever you’re initiating or restarting a hormonal method to ensure you’re protected during the “window” before the hormones have reached full effectiveness.
- Day-1 Start: Apply your first patch on Day 1 of menstrual bleeding. No backup needed.
- Sunday Start: Apply on the first Sunday after menses begins. Use backup condoms for 7 days.
- Quick-Start Anytime: Apply the patch on any day; use backup condoms for the first 7 days of the first patch.
- Re-application After Loss: If patch off >24 hours, reapply or replace and use backup for 7 days.
Effectiveness
- Perfect-use failure rate: ~0.3% per year
- Typical-use failure rate: ~7% per year
Key Benefits
- Once-weekly application → easier adherence than daily pills
- Same cycle regulation and non-contraceptive benefits as COCs
- Can be used by people who might be too busy to remember a daily pill, have difficulty swallowing pills, or have gastrointestinal absorption issues that may make the pill less effective.
Potential Risks & Side Effects
- Similar to COCs, with a slightly higher estrogen exposure→ possibly higher VTE risk
- Skin irritation or rash at application site
- Breakthrough bleeding, breast discomfort, nausea
Usage Considerations & Adherence
- Apply to clean, dry skin (buttock, abdomen, upper outer arm, upper torso) once weekly for 3 weeks, then 1 week off.
- Patch may detach—if off >24 hours, follow missed-dose protocol.
Contraindications & When to Seek Care
- Same as COCs, with heightened vigilance for VTE signs
- Avoid in females >90 kg (198 lbs) or BMI >30 (BMI = body mass index)
- Effectiveness of this medication may be lower in females with a BMI between 25 and 30
4. Vaginal Ring
Mechanism of Action
Flexible ring inserted intravaginally that releases estrogen and progestin locally. Suppresses ovulation and alters cervical mucus and endometrium like COCs.
Initiation & Backup Contraception
Here are the different ways on when to start using vaginal ring birth control, as well as whether you may need back-up contraception depending on when you start the birth control. Backup contraception—most commonly condoms—is recommended whenever you’re initiating or restarting a hormonal method to ensure you’re protected during the “window” before the hormones have reached full effectiveness.
- Day-1 Start: Insert ring on Day 1 of your period. No backup needed.
- Sunday Start: Insert on the first Sunday after menstruation begins. Use backup condoms for 7 days.
- Quick-Start Anytime: You may insert the ring on any day; use backup condoms for 7 days after insertion.
Note - Ring Expulsion: If ring is out >3 hours, rinse with lukewarm water, reinsert, and use backup condoms for 7 days.
Effectiveness
- Perfect-use failure rate: ~0.3% per year
- Typical-use failure rate: ~7% per year
Key Benefits
- Monthly administration (one 3-week ring → 1 week ring-free)
- Steady hormone levels → fewer peaks/troughs → potentially less breakthrough bleeding and mood swings
- Easy to use and quickly reversible
Potential Risks & Side Effects
- Vaginal irritation, discharge, or discomfort
- Same systemic risks as COCs (blood clots, hypertension, headaches, breast tenderness)
- Ring expulsion (reinsertion needed if expelled >3 hours)
Usage Considerations & Adherence
- Self-insert on Day 1 of cycle or Sunday after menses start; keep in place for 21 days, remove for 7 days.
- If removed >3 hours, use backup contraception for 7 days.
Contraindications & When to Seek Care
- Same as COCs.
- Remove ring and seek care if you experience severe leg pain/swelling, chest pain, or neurological symptoms.
General Points on Alternatives
- Emergency contraception: Plan B (levonorgestrel) or Ella (ulipristal acetate) can be used after unprotected intercourse; best when taken as soon as possible.
- Long-acting reversible contraception (LARC): IUDs (hormonal or copper) and implants offer >99% efficacy, minimal user adherence concerns, and are recommended if long-term contraception is desired. These are not available options via telehealth and must be done in person.
- Barrier methods: Male/female condoms, diaphragms, cervical caps, spermacides, —can be used alone or in combination with hormonal methods. Condoms also offer STI protection.
- Sterilization: Tubal ligation or vasectomy—permanent methods for those who desire no future fertility.
- Natural methods: Fertility awareness–based methods require daily monitoring and have higher failure rates. Effectiveness of Lactational Amenorrhea Method is dependent on women exclusive breastfeeding – no pumping, have not resumed regular menses, and are within the first 6 months post-partum.