Here’s What You Need to Know About the New OTC Birth Control Pill & Perimenopause

Opill and Perimenopause

First things first, I would like to commend the FDA for clearing the way for the first over the counter oral contraceptive. The American College of Obstetricians and Gynecologists has advocated for OTC oral contraceptives since 2019. Given that over 50% of all pregnancies are unintended, access to reliable and affordable birth control is essential in the post Roe v. Wade era. But many of you have questions about what exactly is the Opill and who is it for, so I’d like to answer a few of these questions for you.

What exactly is the Opill?

Opill is a progestin only birth control pill. Progestin only pills are not new and have been used for decades. The good news is that progestin only pills are over 90% effective, making them the most effective over the counter contraceptive on the market. The Opill uses the synthetic progestin norgestrel which has been used in many older combination oral contraceptives. There are many other progestin only pills available by prescription which contain different but equally effective progestins.  Progestin only pills are what are called ‘mini-pills’. Contrary to popular belief, low dose and ultra-low dose combination pills (containing both estrogen and progestin) are not minipills. 

How does it work?

Progestin only pills work essentially two ways. They thicken the cervical mucus making it difficult for sperm to penetrate. Think of it like a condom in pill form. The thickened cervical mucus provides an actual barrier to conception. Secondly, progestin only pills can also suppress ovulation but they are less efficient in doing so than combination pills. Ovulation can occur in up to 40% of cycles with the progestin only pills which is why the barrier function is so important. Missed or late pills carry a higher penalty in terms of failure rate than combination pills because ovulation is inconsistently suppressed. Progestin only pills should be taken every day at the same time  and no more than 3 hours late to maintain their effectiveness. If pills are taken late or missed, backup contraception is needed for 2 days.

Who are they for?

Progestin only pills can be used by any woman who desires effective contraception. Because there is no estrogen in the minipill, anyone for whom combination oral contraceptives are contraindicated, such as smokers over 35, those with familial blood clotting disorders and known cardiovascular disease, can safely take progestin only pills.

Wait, I thought synthetic progestins were bad. Are there any bioidentical progestin only birth control pills?

Short answer, no. All progestins used in birth control pills and some used in menopausal hormone therapy are synthetic. Even micronized bioidentical progesterone is synthetic. Synthetic simply means the progestins are man made. There are no naturally occurring progestins unless you want to harvest it from pregnant women’s urine (which I don’t recommend, but it has been tried).  The progestins used in Depo-Provera, hormonal IUDs, emergency contraception and Implanon all contain synthetic progestins. And to address the first issue, not all progestins are bad. Some are just less good. They are necessary and quite effective in the use in pre- and perimenopausal women for contraceptive purposes and for balancing the effects of estrogen in menopausal hormone therapy.  The type and the dose of the progestin depends upon individual tolerability and the specific indication. The good news is that even if one type doesn’t agree with you, we have several alternatives to choose from.

What about the use of progestin-only pills in perimenopause?

For perimenopausal women who are asymptomatic, in need of birth control and have contraindications to the use of combination oral contraceptives such as smoking, hereditary blood clotting disorders, liver disease or a history of stroke/cardiovascular disease, progestin only birth control pills can be safely used. 

Do progestin only pills treat menopausal symptoms?

Since there is no estrogen in the mini-pill, common symptoms of perimenopause such as hot flashes, night sweats, brain fog and mood disturbances will most likely not be addressed by progestin-only pills.

Do progestin-only pills help with irregular or heavy bleeding commonly seen in perimenopause?

The answer is a big– maybe. Progestin only pills typically do not control irregular bleeding as reliably as combination pills. In fact, one of the side effects of progestin only pills is irregular bleeding even in women with regular cycles. The typical bleeding profile of progestin only pills can range from no periods, irregular spotting or bleeding between cycles to regular cycles. When cycle control is needed, combination pills do a much better job. 

So, perimenopausal people, how does the over the counter pill change what we recommend? The answer is really not much. For symptomatic women during the menopausal transition, a combination oral contraceptive or estradiol with an added progestin (usually micronized progesterone, but others can be used as well) is still the first line of treatment. But let’s be clear, this is a step in the right direction. The key that I want to emphasize here is affordability. For women who have insurance, contraceptive coverage, free of charge, is mandated by the Affordable Care Act. For women and girls in need of reliable contraception who do not have insurance coverage or access to a medical provider, this medication can be a godsend. Let’s hope that when the price of this medication is announced it enters the market at a price point accessible to all who need it. This is the most tangible and meaningful step in reducing unplanned pregnancies that we’ve seen in years. So let’s take a moment to celebrate, and let’s use this momentum to increase advocacy for women’s health in perimenopause and beyond.