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2In this analysis of use of the so-called third generation pills that appeared in the 1980s, the authors examine the mechanisms responsible for the emergence of new inequalities. Different types of contraceptive pills containing oestrogen and progestogenMost hormonal products authorized for sale in France as contraceptives contain both an oestrogen and a progestogen.
The analysis of access to third generation, non-reimbursed, oral contraceptives was conducted on 1,041 women using a combined oestrogen-progesterone pill.
7For the satisfaction study, three groups of users were identified according to the chemical composition of the pill.
9Social differences in access were studied by comparing the social and demographic characteristics of women using a reimbursed pill (first or second generation) with those of women using a non-reimbursed pill (third generation). 11We examined whether the type of pill used had a specific effect, “all other things being equal”, on the level of satisfaction reported. 18The inequalities in access to contraception in general and to medical contraception in particular observed in the 1970s and 1980s have thus decreased substantially, initially for use of the pill, and subsequently for use of the IUD. 19In 2000, more than one in three pill users (39%) used a third generation pill not reimbursed by the social security.
20This diffusion of the third generation pills seems to have affected different social groups in different ways (Table 2).
21There are marked social differences: 32% of women in households where monthly income per person is below 560 euros use a third generation pill, but the proportion is 51% where income per person is above 990 euros. 22Women in managerial positions are also more likely to go to a gynaecologist for their contraception (90% against 50% among manual workers), and gynaecologists are much more likely than general practitioners to prescribe third generation pills. 23The typical profile of the third generation pill user is thus a woman who is highly educated, has managerial-level employment and complementary health insurance, and who goes to a gynaecologist for her contraception: 70% of pill users in the group of women with these characteristics use a third generation pill. 26In total, 86% of women who used the pill reported that this method suited them “completely”, 10% “fairly well” and 4% “not very well or not at all” (Table 6).
27A slightly higher proportion of women using first or second generation pills (88%) than using third generation pills of the same (84%) or lower dose (80%) reported that this contraception suited them completely (p= 0.06). 28On the whole, younger pill users, those who were not in a couple and those with no children were most likely to report being completely satisfied with their method of contraception (Table 6). 29The pill users who wanted a child straight away or within the year were not more likely to be dissatisfied with their contraceptive method.
30As has been observed among German women (Oddens, 1999), women who have not experienced contraceptive failure in general, and with the pill in particular, are more likely to report being completely satisfied with their contraception. 31In total, the women using first or second generation pills were not less satisfied than the others. 32Although these new products are supposed to have fewer side-effects than earlier pills, it may be wondered whether the lower level of satisfaction expressed by women using low-dose third generation pills results from side-effects that are in reality greater or whether these users constitute a group selected by some special sensitivity, independent of the type of pill used. 33Except for headaches, French users of low-dose third generation pills do not report more side-effects (weight gain, long or heavy periods, nausea, breast pain) than those using a higher dose third generation pill or a first or second generation pill (Table 8). 35We tested for this prescription bias by selecting women who were using the pill for the first time.
36We cannot, however, exclude the possibility that this lower level of satisfaction reflects not only a prescription bias but also the fact that these pills really are less popular with women. 37The data from the COCON survey, which reflect the point of view of women and not those of prescribing doctors or manufacturers of hormonal contraception, do not therefore allow us to conclude that women are more satisfied with third generation pills, at least not on the basis solely of the indicator of satisfaction used here. 39The long-term effects on women’s health of second and third generation pills are very similar. 40For the present, giving women access to an inexpensive generic low-oestrogen dose third generation pill remains a topical issue.
Since contraception was legalized in France in 1967, there has been a sustained increase in use of medical contraception, notably third generation contraceptive pills that are not reimbursed by the social security. For all my male readers (and male family members), today might be a post you’ll want to skip. Before Joe and I got married, I started taking the pill (B-Yaz to be exact) because, well, I wasn’t aware there was any other option.
But when push came to shove, the pill won out over my misgivings because of one simple fact: convenience.
About six months ago (a little over a year after starting the pill) I visited my doctor for my yearly exam and to discuss other options to replace my current from of birth control. I have never had trouble with the pill and was on for 5+ years but just recently went off…day to day, I haven’t felt different at all but my skin is a mess!
I would love to stop taking the Pill due to many of the side efffects mentioned in your post and the comments, particularly decreased libido. My doctor pretty much gave me the same speech (and had me try out another pill for a month, with which I had the same results), and in the end, I just decided to stop taking anything.


You have no idea how comforting it is to know that I wasn’t crazy for thinking that I felt the way I did when taking bc pills.
I found that the birth control pill gave me far more unpleasant side effects than the nuva ring. The continual renewal of contraceptive products—the emergency pill, the female condom, improved contraceptive implants, new types of IUD—ensures a wide relevance for the analysis presented here.
The present situation is due specifically to the trend in use of the contraceptive pill, whereas use of the intrauterine device (IUD) has levelled off since 1988 following a period of strong growth (see Table 2 in the introductory article). Second, we analyse the effect of social class on oral contraceptive use in particular, in order to capture and interpret the logics behind any social inequalities in access to the third generation contraceptive pill. These pills are often poorly tolerated, because they disrupt the menstrual cycle (bleeding, irregular cycle, amenorrhoea, functional ovarian cysts etc.).
The interactions between pill type and the analytical variables listed above were thus tested for. Older women, women with a low educational level, farmers and unskilled manual workers were considerably less likely than other women to use any form of contraception, and the pill and the IUD in particular (Toulemon and Leridon, 1992). Analysis of recourse to the third generation contraceptive pill that is not reimbursed by the social security will allow us to reveal shifts in the pattern of social inequalities affecting access to new oral contraceptive products. The data from the COCON survey accord perfectly with the industry sales figures, which show that the spread of third generation pills was rapid between 1988 and 1992, then slowed sharply and seems to have reached a plateau by 1996 (Figure 1).
The distribution of pill users according to pill type shows that women under 20 and those with two or more children are less likely to use a third generation pill. Conversely we observed that women using low-dose third generation pills reported being significantly less satisfied.
The proportion is 60% among women using a third generation low-dose pill (15-20 µg of ethinyl estradiol). Controlling in the model for the reporting or not of headaches does not affect the relationship between pill type and satisfaction. To test this we would need to be able to measure the satisfaction these users felt if they were using another type of pill, which would require a survey protocol different from that of the COCON survey, of the randomized trial variety. In the early 1980s, access to the pill and the IUD was characterized by sharp disparities, with women from the most advantaged backgrounds being much more likely to use these methods.
Third generation pills are associated with a slightly increased risk of venous thromboembolism (Jick et al., 2000) but this risk affects only a very small number of women.
The more varied the contraception made available, in terms of pill type and more generally of methods of contraception, the greater chance women will have of finding the method that is best suited to their social, relational and sexual situation as well as to their physiology. I did a lot of research online (reading articles, message boards about people’s personal experiences, talking with friends who were on the pill), and found that many of my symptoms were actually very common. Naively, I expected her to have a lot of other solutions that were just as easy and effective, but without the hormonal impact that came with taking the pill.
I know a lot of people who have had no ill side effects from the pill, and others who take it to help with their PCOS or skin issues and are incredibly happy with it. I love my Savior, Jesus Christ, followed (in no particular order) by my family, coffee, cooking, a good sweat session at the gym, Instagram, early mornings, fall and football.
I have PCOS and I found out that it suppresses the problems instead of helps, and the pill made me absolutely crazy. Shortly after contraceptives were legalized in France, a survey conducted by INED in 1971 on a sample of married women aged 20-44 showed that the contraceptive pill was used by merely 7% of women whose only qualification was the primary school certificate, compared with 23% of women who had the baccalaureat or a higher-education qualification. In 1978, of 100 women who were sexually active and not seeking to get pregnant, 40 reported using the contraceptive pill, compared with 50 in 1988 and 60 in 2000, corresponding to around 5 million pill users today.
If such social inequalities exist, bearing in mind that these new pills are supposed to be better tolerated, we need to examine whether the women using them are indeed more satisfied.
Ten years later, while inequalities remained in overall access to contraception (by educational and socio-occupational level, the most disadvantaged women being least likely to use contraception), these inequalities no longer had any appreciable effect on use of the pill, which had spread to all social groups.
This age effect, which had disappeared in 1988, is probably the result of a large increase in medical contraceptive coverage, here meaning the pill, among younger women: 69% of women aged 20-24 reported using a medical contraceptive method in 2000, against 40% in 1978 (Table 2 in the article by Clementine Rossier and Henri Leridon in this issue). Among women with no qualifications or only a lower secondary certificate (BEPC), 22% used a third generation pill, compared with 56% among those with higher education. One hypothesis is that people from the most advantaged social backgrounds are more attentive to all of the side-effects associated with these low-dose pills and in addition have the financial resources necessary for this contraception. The link observed between duration and satisfaction is probably due to a selection effect over time, but it remains when we limit the analysis to pills that had been on the market for more than 3 years so as to allow for any bias introduced by the changing contraceptive supply (result not shown).
The lower level of satisfaction among users of low-dose third generation pills would thus seem not to be because they are more prone to headaches. This specific effect of pill type remained after controlling for variables linked to satisfaction in the multivariate model presented above (Table 7) and for reporting of headaches (the only side-effect more common among users of third generation pills): the new users of third generation pills remained significantly less satisfied than other women (result not shown).


These social disparities subsequently narrowed considerably, first for the pill only (in the 1990s) (Toulemon and Leridon, 1992), then for the IUD in the late 1990s (de Guibert-Lantoine and Leridon, 1999). On the other hand, their protective effect against myocardial infarction compared with second generation pills is still a subject of debate (Spitzer et al., 2002).
When I first started taking birth control, my primary concern was gaining weight, since that was one of the few negatives I had heard others express about the pill.
One of the main reasons why I’m still on the pill is because my cycles are pretty unpredictable. I’m on the pill, I think it does have a tendency to give me mood swings, but not NEARLY as bad as the ones I had when I was on the depo shot. Low-dose progestogen-only pills are used only as a contraceptive, while higher dose pills also have therapeutic uses, particularly in perimenopausal women (endometriosis, benign breast disease, menstrual cycle disorders). Use of the pill has increased at all ages, although is still lower among older women and married women. Correlatively, women in managerial employment were more likely to use these new pills than women at the other end of the social scale (64% against 17% among manual workers).
It might derive from different pill prescribing practices depending on the “sensitivity” of the women, either as expressed by the women or anticipated by the prescribers.
Our concern here has been to identify a specific effect of pill type on the satisfaction felt by women, rather than to analyse the level of satisfaction that women feel towards their method of contraception.
The COCON data show for the first time that social disparities now concern the type of pill used. Given that no link has so far been established between pill type and user satisfaction it seems that the social inequalities in access to third generation pills are not accompanied by health inequalities.
At the beginning of the 1980s, access to the pill and the intrauterine device (IUD) was characterized by large inequalities.
And more often than not, I’ve found that a large majority of my friends have had a less than pleasant experience with the most common form of birth control, the pill.
These data probably reflect the increase in the average duration of pill use, and the growing recourse to progestogen-only pills that tend only to be prescribed for older women and in particular for those who smoke or who have medical contra-indications for oestrogens. This method seems to be increasingly restricted to women over age 40 and those who have completed their families.
Our multivariate analysis (Table 7) confirms these findings, except concerning the effects of age, marital status and having become pregnant while on the pill. Our hypothesis is that there may be such a “prescription bias”, originating in a tendency of doctors to prescribe a lower-dose third generation pill to women for whom they believe it is particularly suited, in view of the weaker anticipated side-effects. The effects on the body remain to be assessed, which will be possible through analysis of follow-up data on the cohort in an epidemiological perspective, allowing further progress to be made on this question and providing material for the debate over social security reimbursement of third generation pills. These inequalities subsequently declined sharply, for the pill in the 1990s and for the IUD at the end of the 1990s. In all honesty, my greatest complaints with the pill were my decreased libido and general irritability about everything.
Other brands of pills, rings, IUD’s (surgically implanting something gave me the creeps), which all seemed to have the same set of side effects and risks.
I was on the pill for a while and then the NuvaRing for a few years which I loved until it suddenly gave me a lot of pain and a decreased libido (just like you were saying).
In 1967, there was only one type of contraceptive pill, the “first generation combined contraceptive pill”, but in 1974 the “second generation pill”, containing lower doses of oestrogen, appeared on the market (see box on next page), and 1982 saw the arrival of the “third generation” oral contraceptives. If these women are less likely to be satisfied with their contraceptive method, irrespective of the product used, this would lead to a higher percentage of dissatisfied users of third generation pills compared with users of first and second generation pills.
The latter contain the same dose of oestrogen as the second generation pills but a new progestogen that has fewer androgenic effects (weight gain, hair growth, acne).
I no longer experience the side effects I did on the pill, and I can feel confident knowing I am using the most effective form of birth control. In the time between having Eli and starting the pill my skin was the worst it’s been since I was in high school! They all seemed to brush of my complaints of moodiness and depression from the pill like they were nothing. Prescribed with increasing frequency and not refunded by the social security, these third generation contraceptive pills are supposed to be better tolerated by women because the type of progestogen they contain has fewer androgenic effects and because some have a smaller oestrogen component (Spira, 1993).
Thus, the prescription of third generation pills by the latter is independent of educational level and socio-occupational category, whereas gynaecologists prescribe more non-reimbursed pills to women who are in managerial employment and are the most highly qualified (Table 5).



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