Types of Birth Control and the Specific Risks of Each

Combined Oral Contraceptives (The Pill)

The most-prescribed form. Contains synthetic estrogen (ethinyl estradiol) plus a synthetic progestin.

The specific issues:

• Blood clot risk varies by progestin generation: Pills containing newer progestins -- desogestrel, gestodene, drospirenone (Yaz, Yasmin), and cyproterone -- carry roughly double the venous thromboembolism risk of older formulations using levonorgestrel or norethisterone [3]. Drospirenone-containing pills have been the subject of extensive litigation in multiple countries.
• Depression risk: Combined oral contraceptive users had a 23% increased risk of being prescribed antidepressants in the Skovlund (2016) Danish national cohort of over a million women [1]. Adolescents (ages 15-19) saw an 80% increased risk [1].
• Suicide and suicide attempts: The Skovlund (2018) follow-up using the same Danish registry found hormonal contraceptive users had roughly double the risk of suicide attempts and a tripled risk of completed suicide compared to never-users, with adolescents again most affected [2].
• Breast cancer: The Mørch (2017) NEJM study of 1.8 million Danish women found current users of any hormonal contraception -- including modern low-dose pills -- had a 20% higher relative risk of breast cancer, with risk rising to 38% after 10+ years of use [4].
• Nutrient depletion: B6, B12, folate, magnesium, zinc, selenium, and vitamins C and E are all consistently depleted [6].
• Stroke and heart attack risk: Modestly elevated, especially in smokers, women over 35, and those with hypertension or migraine with aura.

Progestin-Only Pills (the "Mini-Pill")

Often prescribed for women who can't take estrogen -- smokers, breastfeeding mothers, those with clotting risk.

The specific issues:

• Higher depression risk than combined pills: Skovlund (2016) found progestin-only pill users had a 34% increased risk of antidepressant use -- higher than combined pills [1]. Among adolescents, the increase was 120% [1].
• Strict timing required: Most must be taken within a 3-hour window every day or contraceptive effect drops sharply. Missing the window means backup contraception is needed.
• Irregular bleeding is the rule, not the exception: Most users experience unpredictable spotting, prolonged bleeding, or amenorrhea throughout use.
• Lower contraceptive efficacy: Works mainly through cervical mucus and endometrial effects rather than reliably suppressing ovulation, so typical-use failure rates are higher than combined methods.

The Patch (Xulane, formerly Ortho Evra)

A weekly transdermal patch delivering ethinyl estradiol and norelgestromin.

The specific issues:

• Highest depression risk in the Skovlund cohort: Patch users had a 100% increased risk (doubled) of antidepressant prescription -- the highest of any method studied [1].
• Higher systemic estrogen exposure than the pill: The transdermal route bypasses first-pass liver metabolism, meaning systemic estrogen exposure can be roughly 60% higher than with a comparably labeled oral pill. The FDA added label warnings about elevated estrogen exposure and clot risk in 2005-2008.
• Elevated VTE risk: Clot risk is in the same range as combined pills using newer progestins [3].
• Skin reactions and detachment: Local irritation is common; partial detachment compromises effectiveness and is a frequent reason for unintended pregnancy on this method.

The Vaginal Ring (NuvaRing, Annovera)

A flexible ring inserted for three weeks, delivering ethinyl estradiol and a progestin (etonogestrel for NuvaRing).

The specific issues:

• VTE risk comparable to or higher than combined pills: Multiple cohort studies have placed ring users at a similar or modestly elevated clot risk versus oral users [3].
• Same systemic hormone exposure: Despite the local-delivery framing, hormones absorb systemically and produce all the typical side effects of combined contraception, including the depression signal [1].
• Mechanical issues: Expulsion (especially during sex or bowel movements), breakage, and discomfort are reported in a meaningful minority of users.

Depo-Provera (the Shot)

An injection of depot medroxyprogesterone acetate (DMPA) every three months. Long-acting and effective, but the trade-offs are significant.

The specific issues:

• FDA black box warning for bone loss: In 2004 the FDA placed a black box warning on Depo-Provera for significant loss of bone mineral density with long-term use. The warning specifically cautions against use longer than two years unless other methods are inadequate. Bone density partially recovers after stopping but recovery is not always complete, particularly for adolescents who were still building peak bone mass during use.
• Strong progestin-only depression signal: In Skovlund (2016), injectable progestin was grouped with the methods showing the strongest depression and antidepressant-use increase [1].
• Longest fertility delay of any reversible method: Average return to ovulation is 5-8 months after the last shot, with some women waiting 12-18 months for cycles to resume.
• Weight gain: Documented average gain of around 5-10 pounds in the first year, with substantial inter-individual variation. The shot has the strongest weight-gain signal of any commonly used method.
• HIV acquisition concerns in high-risk populations: A randomized trial in sub-Saharan Africa raised concerns about a possible elevated HIV acquisition risk with DMPA versus the copper IUD or implant. The findings were debated, but the WHO updated guidance in response.
• Cannot be discontinued mid-cycle: Once injected, the hormone is in the body for three months. Side effects can't be stopped -- you wait them out.

Nexplanon (the Implant)

A flexible rod inserted under the skin of the upper arm, releasing etonogestrel for up to 5 years.

The specific issues:

• Unpredictable bleeding is nearly universal: About half of users report prolonged or frequent bleeding, especially in the first year. This is the leading reason for early removal.
• Migration cases: Rare but documented cases of the implant migrating into blood vessels or the chest wall, sometimes requiring surgical retrieval. The Nexplanon redesign added a barium sulfate marker to make the device visible on X-ray, but migration still happens.
• Mood effects: Although the implant is studied less than oral methods, Skovlund (2016) included it in the progestin-only depression signal [1].
• Removal complications: Difficult removal can occur if the implant has been placed too deep, requiring ultrasound localization or minor surgery.
• Headaches, acne, and weight gain: Common reasons for discontinuation.

Hormonal IUDs (Mirena, Kyleena, Liletta, Skyla)

T-shaped intrauterine devices releasing levonorgestrel locally for 3-8 years depending on the model.

The specific issues:

• Insertion is painful, often without anesthesia: Most clinics offer no pain control for insertion -- a practice that has come under increasing public scrutiny. Insertion involves dilating the cervix and placing a foreign body in the uterus.
• Perforation risk: Uterine perforation occurs in roughly 1-2 per 1,000 insertions, with notably higher rates in postpartum and breastfeeding women. Perforated devices can migrate into the abdominal cavity and require surgical retrieval.
• Expulsion: Roughly 1 in 20 users experience partial or complete expulsion, often within the first year and sometimes without the user noticing.
• Mood effects despite "local" delivery: Skovlund (2016) found hormonal IUD users had a 40% increased risk of antidepressant prescription [1] -- a striking finding given the marketing emphasis on minimal systemic absorption. Levonorgestrel does enter circulation, just at lower levels than oral progestins.
• Ovarian cysts: Functional ovarian cysts develop in a notable fraction of users; most resolve, but some require imaging follow-up.
• Pelvic infection risk in the first 20 days: Insertion-related PID risk is transiently elevated after placement.
• Breast cancer signal applies here too: Mørch (2017) found the levonorgestrel IUD shared the elevated breast cancer risk seen with other hormonal methods [4].

Copper IUD (ParaGard)

The only widely available non-hormonal IUD. Lasts up to 10-12 years and is over 99% effective [5]. Avoids systemic hormonal effects, but it isn't risk-free.

The specific issues:

• Heavier, longer, more painful periods: Bleeding volume can increase 50-75% on average, especially in the first 3-6 months [5]. Some women never return to baseline cycle length or volume.
• Insertion pain and cramping: Same procedure and same lack of routine anesthesia as hormonal IUDs.
• Perforation and expulsion: Risks comparable to hormonal IUDs.
• Copper toxicity concerns: Disputed but persistently raised. Systemic copper levels typically remain in the standard range, but copper-zinc balance can shift, and a subset of women report symptoms they attribute to copper excess. Solid mechanistic research is limited.
• Anemia from heavier bleeding: Iron deficiency can develop in users with already-low iron stores -- something to monitor with bloodwork.

Emergency Contraception (Plan B, Ella)

Plan B (levonorgestrel) and Ella (ulipristal acetate) are taken after unprotected sex to prevent pregnancy. Not intended for routine use.

The specific issues:

• Reduced effectiveness above certain body weights: Levonorgestrel-based emergency contraception (Plan B) shows substantially reduced effectiveness in women over roughly 165-175 pounds and may be largely ineffective above 195 pounds. This is poorly publicized at the pharmacy counter, where women often buy it without weight-related guidance.
• Hormonal disruption of the next cycle: A high progestin or progesterone-modulator dose typically delays or alters the following period.
• Nausea, headaches, fatigue, breast tenderness: Common in the days following.
• Not a substitute for ongoing contraception: Repeated frequent use has not been adequately studied for long-term safety, and effectiveness drops with repeated use within the same cycle.

Sterilization (Tubal Ligation, Vasectomy)

Permanent procedures sometimes presented as a "set-it-and-forget-it" final answer. They aren't reliably reversible.

Tubal ligation specific issues:

• Permanent: Reversal surgery exists but has limited success rates and is rarely covered by insurance.
• Regret: A meaningful minority of women -- particularly those sterilized before age 30 -- report regret within 14 years. Regret rates are highest in the youngest women.
• If failure occurs, ectopic pregnancy is more likely: Pregnancies after tubal ligation are disproportionately ectopic, which can be life-threatening if not caught early.
• Surgical risks: General anesthesia and abdominal surgery carry their own complication risks.

Vasectomy specific issues:

• Permanent: Reversal is technically possible but expensive, often unsuccessful, and not reliably covered by insurance.
• Post-vasectomy pain syndrome: A small percentage of men develop chronic scrotal or testicular pain that can persist long-term.
• Failure can occur: Men must use backup contraception for several months after the procedure and require a follow-up semen analysis to confirm sterility.
• Sperm granuloma: A small inflammatory lump can form at the vasectomy site in a minority of men.

Spermicides (Nonoxynol-9)

Often used with diaphragms, condoms, or alone.

The specific issues:

• Disrupts the vaginal microbiome and epithelium: Nonoxynol-9 damages vaginal and rectal tissue with frequent use and increases susceptibility to infection.
• Increases HIV transmission risk in high-risk populations: The WHO recommends against nonoxynol-9 for HIV-risk populations because frequent use produces lesions that facilitate viral entry.
• Lower effectiveness alone: Roughly 71-82% effective with typical use as a sole method -- one of the weaker stand-alone options.