10. Common side effects

The pill is well tolerated by many, but can - above all in the first months - cause side effects:

• Intermenstrual bleeding/spotting - above all in the first months and with the mini-pill
• A feeling of tension in the breast
• Nausea - mostly at the start
• Headaches
• Mood swings - some women report depressive mood
• A change of libido
• Water retention, a slight weight change
• Skin changes - depending on the preparation an improvement or worsening of acne

Many of these side effects improve after the first 1–3 months of adjustment. If the intolerance persists or is burdensome, a switch to another preparation can help - that is discussed with the gynaecologist. With depressive mood under the pill, clarify medically.

11. The pill with vomiting and diarrhoea

An important, often overlooked point for the safety. Since the pill is taken up via the gastrointestinal tract, vomiting or severe diarrhoea can impair the absorption of the hormones - similar to a missed pill.

• Vomiting within about 3–4 hours after the intake: the pill was possibly not fully absorbed - treat like a missed pill (take a further pill from a replacement blister as soon as possible)
• Severe diarrhoea: can likewise worsen the absorption - treat like a missed pill
• Persistent vomiting and diarrhoea over several days: additional protection with a condom during and for 7 days after the illness
• When in doubt additionally use contraception and heed the package leaflet/medical advice

This point is important especially with gastrointestinal infections and on travel - many do not know that a gastrointestinal illness gone through can weaken the pill protection. Also relevant with the joint use with medications that cause nausea.

12. Interactions with other medications

Certain medications can weaken the effect of the pill (pregnancy risk) or be influenced themselves.

Important: with every new medication intake - also herbal remedies such as St John's wort - it should be checked whether the pill effect is impaired. When in doubt, additionally use a condom and ask a doctor/pharmacist. More under interactions of medications and taking medication correctly.

13. The pill and antibiotics

One of the most common questions - and an area in which the knowledge has changed. For a long time the blanket warning applied that all antibiotics weaken the pill. By the current state, that is more differentiated:

• Most common antibiotics (e.g. amoxicillin, doxycycline, most others) do not relevantly weaken the pill by the current data situation - the earlier blanket warning is regarded as outdated
• A real exception: rifampicin and rifabutin (antibiotics against tuberculosis and certain infections) are strong enzyme inducers and weaken the pill clearly - here additional/other contraception is mandatory
• An indirect effect: if an antibiotic causes vomiting or diarrhoea, the pill absorption can be impaired (see the vomiting/diarrhoea chapter)

Practical recommendation: with most antibiotics, no additional protection is necessary - except with rifampicin/rifabutin or when gastrointestinal side effects occur. When in doubt or for safety, a condom can additionally be used during the antibiotic therapy. With uncertainty, ask a doctor/pharmacist.

14. The pill and smoking

A particularly important combination, because it considerably raises the cardiovascular risk. Smoking and the oestrogen-containing combined pill together clearly raise the risk of thromboses, heart attack, and stroke - the effects reinforce each other.

• Smokers under 35 years: a raised risk that rises with the number of cigarettes
• Smokers from 35 years: the combined pill is here as a rule contraindicated - the cardiovascular risk is too high
• Alternatives for smokers (above all from 35): the oestrogen-free mini-pill or non-hormonal methods (e.g. a copper coil)
• Stopping smoking lowers the risk clearly and broadens the contraceptive options

15. Benefits beyond contraception

Besides contraception, the pill has a range of further effects that are used therapeutically:

• A more regular, weaker, and less painful cycle - with heavy or painful menstrual bleeding; see period pain
• Relief of period pain and premenstrual complaints (PMS/PMDD)
• Improvement of acne - certain combined pills work favourably on the skin appearance
• Treatment with PCOS (polycystic ovary syndrome) - cycle regulation, relief of increased body hair/acne
• Relief with endometriosis - above all in the long cycle
• Postponement of the menstrual bleeding possible (e.g. on holiday) - on medical instruction
• A possible risk reduction for certain cancer types (ovarian and uterine cancer) with longer use

These additional benefits are often reasons why the pill is also prescribed independently of the contraceptive wish. But they must always be weighed against the risks (above all thrombosis).

16. When to the doctor? (warning signs)

• Signs of a thrombosis: swelling/pain/overwarming of a leg - immediately (an emergency)
• Sudden shortness of breath, chest pain, coughing up blood - suspected pulmonary embolism (an emergency)
• Sudden severe headache, visual disturbances, paralysis, speech disorder - suspected stroke (an emergency)
• Newly occurring or worsening migraine, especially with aura
• Strong abdominal pain, yellowing of the skin
• A clear rise in blood pressure
• Persistent intermenstrual bleeding or absent bleeding (suspected pregnancy)
• Burdensome mood changes or depressive mood
• Before planned larger operations or longer immobilisation (thrombosis risk)
• With several missed pills and uncertainty about the protection

17. What you can do yourself: 10 golden rules

1. Take daily at the same timeA fixed routine, use a reminder - particularly important with the mini-pill with a narrow time window.
2. With a missed pill, follow the rulesHave the package leaflet to hand and additionally use a condom if needed.
3. With vomiting/diarrhoea, think of a loss of effectVomiting within 3–4 hours or severe diarrhoea: treat like a missed pill.
4. Know the thrombosis warning signsSwelling in the leg, shortness of breath, chest pain, paralyses - in an emergency call the emergency services immediately (112; or 999/112 in the UK).
5. Do not smokeAbove all not in combination with the combined pill - from 35 contraindicated.
6. Move on long journeysThrombosis prophylaxis on flights and long car journeys.
7. Raise the pill before operationsIt may be paused because of the thrombosis risk.
8. Have new medications checkedAbove all rifampicin, antiepileptics, St John's wort - can weaken protection.
9. Additionally a condom if neededThe pill does not protect against sexually transmitted infections.
10. With burdensome side effects, a change of preparationInstead of stopping on your own, speak with the gynaecologist.

18. How brite supports you with the pill

• Intake reminder: take the pill daily at the same time - brite reminds you reliably, particularly valuable with the time-critical mini-pill.
• Interaction check: check rifampicin, antiepileptics, St John's wort, and other substances that can weaken the pill for free.
• Warning-signal information: notes on thrombosis warning signs and when medical help is necessary.
• Health history: document cycle, bleeding, and side effects - helpful for the conversation with the gynaecologist.
• Digital medication plan: all medications clearly laid out to keep an eye on interactions with the pill.

Real-world data: what brite users report

Pill experiences: what women really ask

Pill experiences with different preparations - which is the right one? The choice of the right pill is individual and depends on risk factors, complaints, and tolerability. Levonorgestrel-containing combined pills (e.g. Microgynon, Leios) are regarded as the first choice because of the lowest thrombosis risk among the combined pills. Drospirenone-containing pills (e.g. Yasmin, Yasminelle) work favourably with acne and water retention, but have a somewhat higher thrombosis risk. Mini-pills with desogestrel (e.g. Cerazette) are oestrogen-free and thus low in thrombosis - suitable with breastfeeding, migraine with aura, smokers. With acne, antiandrogenic pills with cyproterone acetate are possible, but with a raised thrombosis risk - only after a strict indication. The final choice is made by the gynaecologist after an individual risk-benefit weighing.

Stopping the pill - what happens to the body? After stopping, it can take some months until the natural cycle settles in again - on average 1–3 months, sometimes longer. What comes back: one's own cycle with ovulation, possibly heavier or more painful menstrual bleeding than under the pill, acne can recur (above all after antiandrogenic pills), mood swings before the period (PMS). Pregnancy: is possible immediately after stopping - with the mini-pill even faster than with the combined pill. Anyone who wants to stop should discuss this with the gynaecologist and listen well to the body in the first months. Even short use breaks change the hormone balance noticeably.

The pill and the wish for children - how long does it take until pregnancy? The pill does not impair fertility in the long term. Most women become pregnant within 3 to 12 months after stopping - comparable to women who have never contracepted hormonally. With long pill use, it can sometimes take somewhat longer until the cycle settles in again. Practical tips: stop 2–3 months before a planned wish for children, begin folic acid supplementation (at least 0.4 mg daily, ideally 3 months before the start of pregnancy), lifestyle optimisation (weight, alcohol, smoking). With an absent pregnancy after 12 months, a gynaecological clarification is sensible.

Pill experiences with acne - really better? Yes, often clearly - the pill is one of the effective therapies with hormonally caused acne, above all in women with PCOS or hyperandrogenism. Particularly effective: pills with antiandrogenic progestogens such as cyproterone acetate (Diane-35), drospirenone (Yasmin), or dienogest (Valette). These bind to androgen receptors and reduce the sebum production. When to expect: first improvement after 2–3 months, full effect after 6 months. Important: antiandrogenic combined pills have a somewhat higher thrombosis risk - in the German guidelines only for acne with a clear indication and with good tolerability. Alternatives for acne without a hormonal profile: local treatment, antibiotics, in severe cases isotretinoin.

The pill and weight gain - myth or reality? Largely a myth - modern low-dose pills do not lead to a relevant weight gain in most women. What can happen: slight water retention in the first months (1–2 kg, often temporary), with drospirenone-containing pills even rather a dehydrating effect, sometimes appetite changes. What rarely happens: clear, persistent weight gain over several kilos - this is mostly explicable with individual factors (lifestyle, age, other medications). With clear burdensome weight gain, a change of preparation should be discussed with the gynaecologist - sometimes another pill with a different progestogen or a switch to a non-hormonal method helps.