Birth control pill types: 8 pills compared by hormone and dose

There are broadly 8 types of birth control pill, and the difference between them comes down to two things: which progestogen it contains and how much oestrogen. Together those two determine your bleeding pattern, the side effects you may notice and how high your clot risk sits. Below are the eight types, with the active ingredients, the dose and what each is usually prescribed for.

This overview is meant to help you prepare the conversation with your GP or gynaecologist, not to choose from on your own. Which pill is appropriate depends on your symptoms, your medical history and your personal risk of thrombosis.

The 8 types of birth control pill at a glance

The doses come from the patient leaflets and the Dutch Farmacotherapeutisch Kompas. Brand names and availability differ by pharmacy, and most pills also exist as a generic with the same composition.

1. Second-generation pill with levonorgestrel (30 micrograms)

This is the pill most people in the Netherlands start with. It contains 30 micrograms of ethinylestradiol and 150 micrograms of levonorgestrel, a second-generation progestogen. Of all the combined pills, the measured clot risk for levonorgestrel is the lowest.

Levonorgestrel has a mildly androgenic profile. For some women that means slightly oilier skin or more acne than on a third or fourth-generation pill. In exchange, the bleeding pattern tends to be predictable.

2. Second-generation pill at a low dose (20 micrograms)

Same substance, less oestrogen: 20 micrograms of ethinylestradiol with 100 micrograms of levonorgestrel. This version is often chosen by women who had tender breasts, nausea or headaches on the standard dose.

The trade-off is its mirror image. With less oestrogen, breakthrough bleeding is somewhat more common, particularly in the first three months. For many women that settles as the body adjusts.

3. Third-generation pill with desogestrel

Desogestrel is less androgenic than levonorgestrel, which is why these pills are more often chosen when acne, oily skin or unwanted hair growth play a role. The oestrogen dose is 20 or 30 micrograms depending on the version.

The downside sits in the figures further down: with desogestrel the clot risk is roughly twice that of levonorgestrel. That is one reason it is usually not the starting choice.

4. Third-generation pill with gestodene

Gestodene belongs to the same generation as desogestrel and has a comparable profile: little androgenic activity, and a clot risk higher than levonorgestrel. The gestodene dose is low, 75 micrograms, combined with 20 or 30 micrograms of ethinylestradiol.

In practice gestodene is often used for women who kept bleeding irregularly on another pill, because for some it makes cycle control more stable.

5. Fourth-generation pill with drospirenone

Drospirenone is the progestogen in Yasmin and Yaz. It is related to spironolactone and has a mild diuretic and anti-androgenic effect, so women often choose it for acne or a sense of holding fluid.

The clot risk sits in the same band as the third generation, so higher than levonorgestrel. Drospirenone can also slightly affect potassium levels, which matters with kidney or adrenal conditions or when taking certain blood pressure medications.

6. Diane 35 with cyproterone acetate

Diane 35 is strictly speaking not a contraceptive pill. In the Netherlands it is registered as a treatment for androgen-dependent complaints such as moderate to severe acne and unwanted hair growth, and it also suppresses ovulation. It contains 35 micrograms of ethinylestradiol and 2 mg of cyproterone acetate, a strong anti-androgen.

After a European re-evaluation in 2013, stricter conditions apply: it is prescribed when other treatments have not helped enough, and not alongside another hormonal contraceptive. The clot risk is higher than for a levonorgestrel pill.

7. The mini pill with desogestrel, without oestrogen

The mini pill contains only a progestogen, 75 micrograms of desogestrel, and no oestrogen. That makes it usable in situations where oestrogen is better avoided, for example while breastfeeding, with migraine with aura, or with an elevated clot risk.

The bleeding pattern is the biggest difference from the combined pills. Roughly one in five women stops menstruating altogether, while a similar share keeps spotting unpredictably. There is no pill-free week: you take one every day.

8. The pill with natural oestrogen

In Qlaira and Zoely the synthetic ethinylestradiol is replaced by estradiol or estradiol valerate, a form closer to the oestrogen your body makes itself. Qlaira pairs it with dienogest, Zoely with nomegestrol acetate.

These pills are used among other things for heavy menstrual bleeding. Less comparative research is available on the clot risk of these newer combinations than for the older generations, which is why the Farmacotherapeutisch Kompas lists that risk as not established.

Two women, the same complaint, a different pill

Imagine two women of 28 with the same complaint, acne along the jawline. One takes Microgynon 30, with 150 micrograms of levonorgestrel. The other takes Yasmin, with 3 mg of drospirenone. After six months the second woman's skin is noticeably calmer, while the first sees little change.

That is not a coincidence, and it does not make one pill better than the other. Levonorgestrel is mildly androgenic and can keep acne going for some women, while drospirenone acts against androgens. The bill shows up in the figures below: with levonorgestrel the clot figures sit at 5 to 7 per 10,000 women a year, with drospirenone at 9 to 12. One woman trades skin for risk, the other the reverse. That is exactly the trade-off you weigh with your doctor, and it lands differently for everyone.

What do those generations actually mean?

A pill's generation says something about when the progestogen was developed and how androgenic it is. Second generation means levonorgestrel or norethisterone, third generation desogestrel or gestodene, fourth generation drospirenone. The oestrogen component is the same across almost all generations: ethinylestradiol.

Worth knowing: a newer generation is not automatically an improvement. The later generations were developed to reduce androgenic side effects such as acne, and they do, but the clot risk did not come down with them.

How does clot risk differ by type?

Clot risk differs by progestogen rather than by brand. The European Medicines Agency re-evaluated the combined pills in 2014 and expressed the figures as the number of women per 10,000 who develop a venous thrombosis in a year.

Two things matter here. The absolute risk stays small in every case: even 12 per 10,000 means well over 99.8 percent of users do not develop a clot that year. And the risk is highest in the first year of using a pill, or when you restart after a break.

Personal factors weigh more heavily than the difference between two pills: smoking, excess weight, a previous thrombosis, a long operation or a clotting disorder in the family. Your GP weighs those in the conversation.

What the pill does to your hormone levels

A combined pill suppresses your own hormone production. Your FSH, LH, oestradiol and progesterone drop to low values, which is exactly what the pill is meant to do. For a hormone test that has a practical consequence: values measured while you are on the pill say little about your own cycle.

Something else is at play. Ethinylestradiol raises your SHBG, the protein that binds testosterone in your blood. More SHBG means less free testosterone. A testosterone value measured on the pill can therefore look low without that saying anything about your situation off the pill.

That is why some women choose to map their hormones before starting, or a few months after coming off the pill, once their own cycle has resumed. A hormone test for women may offer insight into a number of these values.

For more on what hormonal contraception does to your hormone balance, see our overview of birth control and your hormones.

Frequently asked questions about birth control pill types

How many types of birth control pill are there?

There are eight main types, split between combined pills with oestrogen and a progestogen, and the mini pill with a progestogen only. Within those types there are dozens of brand names and generics, but the composition almost always falls into one of these eight groups.

What is the difference between the combined pill and the mini pill?

The combined pill contains oestrogen and a progestogen and usually has a pill-free week. The mini pill contains only a progestogen, is taken continuously without a break, and shows no demonstrable increase in clot risk. Its bleeding pattern is often less predictable.

Which birth control pill has the lowest clot risk?

Among the combined pills the figures for levonorgestrel are lowest, 5 to 7 cases per 10,000 women a year against 9 to 12 for desogestrel, gestodene and drospirenone. For progestogen-only pills no increase has been demonstrated. Your personal risk factors weigh heavily in this.

Can you simply switch pills?

Switching happens in consultation with your doctor, because how you change over determines whether you stay protected. After a switch it can take two to three months before your bleeding pattern and skin settle on the new composition.

Can you test your hormones while taking the pill?

You can test at any time, but the result then describes your situation under the influence of the pill rather than your own cycle. FSH, LH, oestradiol and progesterone are suppressed and your SHBG is raised. For a picture of your own hormone balance, measuring before starting or a few months after stopping is more informative.

How do I know which pill suits me?

You work that out with your GP or gynaecologist, because it depends on your symptoms, your age, whether you smoke and whether thrombosis runs in your family. What this overview mainly does is help you ask sharper questions: which progestogen is in it, how many micrograms of oestrogen, and why this composition for my situation.

References

• Lidegaard Ø et al. Risk of venous thromboembolism from use of oral contraceptives containing different progestogens and oestrogen doses: Danish cohort study, 2001-9. BMJ 2011. PMID 22027398
• de Bastos M et al. Combined oral contraceptives: venous thrombosis. Cochrane Database of Systematic Reviews 2014. PMID 24590565
• Lidegaard Ø et al. Hormonal contraception and risk of venous thromboembolism: national follow-up study. BMJ 2009. PMID 19679613
• Zimmerman Y et al. The effect of combined oral contraception on testosterone levels in healthy women: a systematic review and meta-analysis. Human Reproduction Update 2014. PMID 24082040
• European Medicines Agency (EMA), review of combined hormonal contraceptives, 2014, and the Dutch Farmacotherapeutisch Kompas

Every blood test result includes a professional assessment from a BIG-registered doctor. For treatment decisions, discuss your results with your GP.