The Pill: Read the Insert

What Five Birth Control Labels Admit — and What Was Never Asked

Synopsis

More than 150 million women worldwide take oral contraceptive pills. The prescribing documents for these drugs — written by the manufacturers, approved by regulators — run to dozens of pages each. They acknowledge blood clots, stroke, heart attack, cancer associations, depression, and suppressed sexual desire. They admit that the long-term effects of current formulations "remain to be determined." They reveal that key pharmacological parameters were never measured for some products, and that clinical trials of roughly a thousand women lasting one year serve as the safety basis for decades of continuous use. What these documents do not contain is any investigation into the cognitive, psychological, or relational effects of suppressing a woman's natural hormonal cycle from adolescence through her reproductive years — including published, replicated research showing the pill alters mate selection. This essay examines what five of the most commonly prescribed birth control pills in the United States say in their own labels, and what was never asked.

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The Yaz prescribing information runs to 33 pages. Sprintec’s is 41 pages. Apri’s is 70. Junel Fe and Aviane are comparable in length. These documents, written by the manufacturers and reviewed by regulators, contain detailed information about what these drugs do to a woman’s body, what they are known to cause, and what has never been studied. More than 150 million women worldwide use oral contraceptive pills [13, 14]. The overwhelming majority have never read these documents. Their doctors, in most cases, have not walked them through the contents. The pharmacist hands over the package. The insert stays folded inside the box.

This essay covers five of the most commonly prescribed birth control pills in the United States [15]. All five contain the same synthetic estrogen, ethinyl estradiol, paired with one of four different synthetic progestins. The pills are Yaz (drospirenone), Sprintec (norgestimate), Apri (desogestrel), Junel Fe (norethindrone acetate), and Aviane (levonorgestrel). Between them, they represent the major classes of combined oral contraceptive on the market today.

What follows is drawn primarily from the manufacturers’ own prescribing documents: the side effects they acknowledge, the risks they quantify, and the questions they admit they never investigated. Everything here is either documented in the label, published in peer-reviewed literature, or both.

What the Pill Actually Does

Every prescribing document for these five pills describes the same primary mechanism of action: suppression of gonadotropins, resulting in inhibition of ovulation [1–5]. The Apri label adds two further mechanisms: changing cervical mucus to slow sperm movement and altering the endometrium to reduce the likelihood of implantation [3]. Sprintec, Junel, and Aviane describe the same triad [2, 4, 5].

What this means in practice is that the pill floods the body with synthetic hormones at levels sufficient to convince the brain that the woman is already pregnant. The brain responds accordingly, ceasing to send the follicle-stimulating hormone and luteinising hormone signals that would develop an egg and trigger ovulation. No egg matures. Ovulation does not occur. The pharmacological mechanism is pregnancy mimicry.

In a natural menstrual cycle, a woman’s hormones follow a rhythmic pattern over approximately 28 days. Estrogen rises during the first half, reaching a peak that triggers a surge of luteinising hormone and causes ovulation. After ovulation, the corpus luteum produces progesterone, preparing the uterine lining for possible implantation. If no pregnancy occurs, progesterone falls, the lining sheds, and the cycle begins again. This rhythm is not incidental to female biology. It is a coordinating signal across the brain, cellular repair, bone metabolism, mood, energy, sexual desire, and social behaviour.

The pill replaces this entire sequence with a constant hormonal state. No follicular phase, no ovulation, no luteal phase. The body’s endocrine system is held static in a condition that pharmacologically resembles early pregnancy, where sustained high progesterone signals the hypothalamus that ovulation is unnecessary.

The parallel to pregnancy is exact. During pregnancy, the corpus luteum and later the placenta produce high levels of progesterone, which suppress gonadotropin-releasing hormone from the hypothalamus, which in turn suppresses FSH and LH from the pituitary. No new follicle develops. The system is shut down for the duration. The pill reproduces this shutdown with a synthetic analogue that binds to the same receptors and sends the same suppressive signal. In terms of ovarian function, the result is indistinguishable: the ovaries go quiet and remain quiet for as long as the synthetic signal continues.

The “period” that occurs during the placebo week is not a menstrual period but withdrawal bleeding, a response to the abrupt removal of synthetic hormones when the active pills stop. It was built into the original pill design in the 1960s to make the drug feel more natural and to ease social and religious acceptance. The bleeding serves no physiological purpose. Some newer pill regimens have extended or eliminated the placebo week entirely, making the artificial nature of this bleed explicit.

A woman on the pill does not cycle or ovulate. The rhythmic rise and fall of estrogen, progesterone, testosterone, FSH, LH, and the other hormones that coordinate mood, cellular function, and sexual desire is suppressed and replaced by a flat, synthetic approximation. This state persists for as long as she takes the pill. For many women, that is ten years. For some, twenty or more. For a significant number, from their mid-teens to their mid-thirties.

Many of these women did not begin taking the pill for contraception. Yaz is marketed for three indications: contraception, treatment of premenstrual dysphoric disorder, and treatment of moderate acne in girls as young as 14 [1]. Sprintec carries a similar acne indication [2]. The pathway is common enough: a teenage girl visits her doctor for painful periods or acne and leaves with a prescription for a drug that will suppress her reproductive endocrine system for the foreseeable future. What the drug actually does, that it simulates pregnancy, eliminates her natural hormonal cycle, carries documented cardiovascular and cancer risks, and has never been studied for long-term psychological effects — that conversation does not happen. The prescription is written. The pills are dispensed.

The prescribing documents describe this mechanism in clinical language. What it means for the woman living inside it is left unaddressed.

How You Would Explain This to a Six-Year-Old

Your body has a clock inside it. Every month, the clock sends a message: “Time to get ready.” An egg grows. Your body prepares. If no baby starts, the clock resets and everything begins again.

The pill tells the clock a lie. It sends a chemical message that says: “You’re already having a baby.” So the clock stops. The egg never grows. The monthly reset never happens.

The problem is, that clock doesn’t just control eggs. It controls mood, energy, sleep, who you find attractive, and how your brain grows when you’re a teenager. When you stop the clock, you stop all of it.

Nobody studied what stopping the clock for ten or twenty years does to a woman. That information does not exist, because nobody ran the experiments.

What the Labels Admit

Blood Clots, Stroke, and Heart Attack

All five pills carry the same boxed warning, the most serious warning category the FDA assigns [1–5]. Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptive use, and women over 35 who smoke should not use these products. The cardiovascular risks extend well beyond smoking. All five labels list deep vein thrombosis, pulmonary embolism, stroke, and myocardial infarction as known risks. The Yaz patient labeling states directly that blood clots can form in the legs, lungs, eyes, heart, or brain, and that it is possible to die or be permanently disabled from a blood clot caused by this medication [1].

The baseline risk of venous thromboembolism in women of reproductive age who are not using hormonal contraception and are not pregnant is approximately 1 to 5 per 10,000 women per year. On any combined oral contraceptive, that risk rises to 3 to 9 per 10,000 [1]. But the risk is not uniform across these five pills.

Yaz contains drospirenone, and its own label acknowledges that drospirenone-containing pills carry a higher clot risk than pills containing levonorgestrel or some other progestins [1]. The FDA-funded study cited in the Yaz prescribing information found a hazard ratio of 1.8 for venous thromboembolism in new users of drospirenone pills compared to other available oral contraceptives. When all users were included, not just new starters, the hazard ratio for drospirenone versus levonorgestrel-based pills was 1.5 to 1.6 [1]. The manufacturer’s own label, citing a study the FDA required, reports that their product carries a measurably higher clotting risk than older alternatives.

The Sprintec and Junel labels frame the heart attack risk with a specific estimate: the relative risk for current oral contraceptive users has been estimated at two to six times that of non-users [2, 4]. The risk is modified by age and smoking, but it is present in young, healthy non-smokers.

Cancer

The Yaz patient labeling contains a section titled “Do Birth Control Pills Cause Cancer?” [1]. The first sentence of the answer: “It is not known if hormonal birth control pills cause breast cancer.”

The manufacturer does not say studies show no link. It does not say the evidence suggests no association. It states, in its own document for patients, that they do not know.

What follows is a qualification: some studies, but not all, suggest a slight increase in breast cancer risk among current users with longer duration of use. The Apri label provides additional detail, noting that long-term users of more than eight years and women who started at an early age are at increased risk [3]. In some women, the label states, oral contraceptive use may accelerate the growth of an existing but undiagnosed breast cancer.

Cervical cancer appears across multiple labels. The Apri prescribing document states that long-term COC use contributes to increased cervical cancer risk, though it notes the difficulty of separating this from confounders like sexual behaviour and HPV exposure [3]. Hepatocellular carcinoma is listed as a potential association in both the Apri and Sprintec labels, with risk increasing alongside duration of use [2, 3].

These are the manufacturers’ own assessments, published in their own documents, approved by their own regulators.

The language around cancer in these labels reveals something about the state of the evidence. The phrase “not known” appears repeatedly. Whether oral contraceptives accentuate cardiovascular risk in women with diabetes, hypertension, or abnormal lipid profiles is described in the Apri label as “unclear” [3]. Whether long-term use of lower-dose formulations carries the same cancer associations as the higher-dose pills studied in earlier decades is, as the labels put it, undetermined [2–5]. This conditional, provisional language appears in documents that authorise millions of prescriptions, reflecting an evidence base considerably less settled than the confidence with which these drugs are prescribed.

The Apri label provides one additional detail that does not enter the prescribing conversation. Certain conditions “have been reported to occur or deteriorate with both pregnancy and COC use,” including jaundice, gallstone formation, hearing loss related to otosclerosis, and systemic lupus erythematosus [3]. The connection between pregnancy and pill use in this list is not coincidental. The pill mimics the hormonal state of pregnancy, and the body responds with conditions associated with pregnancy.

Mood, Depression, and the Mind

The Yaz clinical trial data reports mood changes, defined as mood swings, depression, depressed mood, and affect lability, in 2.2% of participants in the contraception and acne trials [1]. In the PMDD trials, the numbers were higher: decreased libido at 2.8%, irritability at 2.8%, fatigue at 4.2%, and affect lability at 2.1%. Depression was listed among the adverse reactions leading to study discontinuation, at 1.4% [1].

The Apri clinical data shows depression reported in 2.3% of women during the first cycle of use [3]. Sprintec lists depression among its side effects, along with nervousness and dizziness [2]. The Junel and Aviane labels carry similar language [4, 5].

The critical context is what these percentages come from. Clinical trials lasting, at most, one year, with sample sizes of approximately 1,000 women. The Yaz contraception trial enrolled 1,027 subjects [1]. The Apri clinical programme enrolled 1,195 [3]. These are the evidence bases upon which the psychological safety of drugs taken by tens of millions of women was established.

The independent evidence that came later tells a different story. In 2016, a Danish national cohort study published in JAMA Psychiatry followed over one million women for up to fourteen years using national registry data, not self-reported questionnaires but actual prescription records and clinical diagnoses [6]. Women using combined oral contraceptives had a 23% higher rate of first-time antidepressant use compared to non-users. Among adolescents aged 15 to 19, the increase was 80%. A follow-up study by the same research group, published in the American Journal of Psychiatry in 2018, found that hormonal contraceptive use was associated with increased rates of both suicide attempts and completed suicides, with the strongest associations again among the youngest users [7].

One million women. Fourteen years. National registry data. A 23% increase in depression diagnoses, rising to 80% in the youngest users. Elevated suicide risk.

The adolescent data is particularly relevant. The Yaz label states that efficacy is “expected to be the same” for postpubertal adolescents under 18 [1]. Expected, not demonstrated in this population with specific safety monitoring. The Yaz acne indication is approved for girls as young as 14. Sprintec, Apri, Junel, and Aviane carry no lower age limit beyond menarche [2–5]. These drugs are routinely prescribed to teenagers, often for acne or period pain rather than contraception, during the period of most active brain development after early childhood. The Danish data showing an 80% increase in antidepressant use among 15- to 19-year-old pill users was generated from precisely this population [6].

The five prescribing documents do not reference the Danish studies. The manufacturer trials tested a thousand women for a year and found depression in about 2%. The independent research tested a million women over fourteen years and found something substantially more concerning. The labels have not been updated to reflect this.

Sexual Desire

The Yaz patient labeling lists “less sexual desire” among its less common side effects [1]. The PMDD trial data quantifies it at 2.8%. This appears as one item in a long list, between “bloating or fluid retention” and “blotchy darkening of the skin.”

The mechanism is straightforward, and the Sprintec prescribing information describes it, though in a different context. In its discussion of acne treatment, the label explains that the combination of ethinyl estradiol and norgestimate increases sex hormone binding globulin (SHBG) and decreases free testosterone [2]. This is presented as a benefit for acne: less testosterone means less sebum production means fewer breakouts.

The same mechanism suppresses the hormone most closely associated with female sexual desire. Ethinyl estradiol, the synthetic estrogen present in all five pills, drives SHBG production up. SHBG binds circulating testosterone, pulling it out of active use. Free testosterone levels drop. The effect is systemic and predictable, not a rare idiosyncratic reaction but the pharmacology working as intended.

Research published outside the manufacturer trials has shown that SHBG levels can remain elevated for months or years after a woman stops taking oral contraceptives, meaning the libido-suppressing effect persists well beyond the last pill. A 2006 study in the Journal of Sexual Medicine measured SHBG in women who had discontinued oral contraceptives and found levels still significantly elevated at the six-month mark compared to women who had never used hormonal contraception [8]. The authors raised the possibility that long-term pill use permanently alters SHBG production. The prescribing documents for these five pills do not mention SHBG persistence after discontinuation. They do not mention discontinuation effects at all.

What Was Never Studied

The most revealing sections of these prescribing documents are the things they admit they do not know. Scattered across the five labels, in clinical language that most patients will never encounter, are frank admissions about the limits of the manufacturers’ own investigation.

The Sprintec, Junel, and Aviane labels contain a statement that belongs in the opening paragraph of every prescription rather than buried in the warnings section [2, 4, 5]. It reads: “The information contained in this package insert is principally based on studies carried out in patients who used oral contraceptives with higher formulations of estrogens and progestogens than those in common use today. The effect of long-term use of the oral contraceptives with lower formulations of both estrogens and progestogens remains to be determined.”

The Apri label carries nearly identical language [3].

The safety data cited in these labels comes largely from studies of older, higher-dose pills, not the pills being prescribed today. The manufacturers acknowledge, in their own documents, that the long-term effects of the products they are actually selling have not been established. These pills have been on the market for years. Millions of women take them daily. The long-term effects “remain to be determined.”

The gaps extend further.

The Junel label states: “The pharmacokinetics of Junel have not been characterized” [4]. The pharmacokinetic data in the prescribing information, describing how the body absorbs, distributes, metabolises, and excretes the drug, is drawn from published literature on other norethindrone products, not from studies of Junel itself.

The Aviane label contains a parallel admission: “No specific investigation of the absolute bioavailability of Aviane in humans has been conducted” [5]. Bioavailability, the proportion of the drug that actually enters the bloodstream, is a fundamental pharmacological parameter. It was not specifically measured for this product.

Both Junel and Aviane labels acknowledge that the effects in women with renal disease, hepatic disease, or in different racial and ethnic populations have not been evaluated [4, 5]. The Yaz label notes that only Japanese and Caucasian women were compared; other ethnic groups were not specifically studied [1].

The clinical trials reveal the narrowness of the evidence base. Yaz received its contraception approval based on a Phase 3 trial of 1,027 women aged 17 to 36, followed for up to one year [1]. Women with a BMI over 35 were excluded. The study population was 87.8% Caucasian. Yaz’s effectiveness for PMDD, one of its marketed indications, was not evaluated beyond three menstrual cycles [1].

Apri’s clinical programme enrolled 1,195 women [3]. Eighty-six percent of participants reported one or more adverse experiences. Twelve percent discontinued due to adverse events. These numbers appear in the prescribing document. They do not appear in the doctor’s office conversation.

But the most important gaps are not the things studied inadequately. They are the things never studied at all. Across all five prescribing documents, representing decades of combined market presence and hundreds of millions of prescriptions, the manufacturers conducted no research on the cognitive effects of long-term hormonal suppression. They did not study the impact of starting these drugs during adolescence, when the brain is still developing. They did not investigate the psychological effects of a decade or more of continuous use, or what happens hormonally, psychologically, and relationally when a woman discontinues after long-term use. They did not examine the effects on partner preference or mate selection.

These questions bear on the most fundamental aspects of a woman’s inner life: how she thinks, whom she desires, whom she chooses as a partner, and how she feels about that choice.

The adolescent brain is a specific concern. The prefrontal cortex, responsible for decision-making, impulse control, and emotional regulation, does not finish developing until the mid-twenties. The hormonal shifts of the natural menstrual cycle are part of the developmental environment in which this maturation occurs. Estrogen and progesterone receptors are distributed throughout the brain, including in regions governing memory, emotion, and executive function. When a 15-year-old begins taking a synthetic hormonal regimen that eliminates her natural cyclical hormone production, she is altering the chemical environment in which her brain is developing. No study in any of these prescribing documents, and no study required by any regulator, has investigated what this means for neurological development over the five, ten, or fifteen years of continuous use that commonly follow.

The discontinuation question is equally unexamined. A woman who has taken the pill from age 16 to age 32 has never experienced adult life with her natural hormonal rhythm. When she stops, typically to conceive, her endocrine system must re-establish a pattern it has been prevented from running for sixteen years. The prescribing documents note that there may be “some delay in becoming pregnant” after stopping oral contraceptives [1–5]. They say nothing about the psychological, emotional, or relational experience of re-entering one’s own hormonal biology after years of suppression.

The Question Nobody Asked

Every person carries a biological signature. The major histocompatibility complex (MHC in scientific literature, HLA in clinical medicine) is a set of markers central to biological self-recognition and cellular identity. The more diverse the MHC profile between two parents, the broader the biological resilience of their children. Research confirms that women are drawn to mates whose MHC profiles complement rather than duplicate their own [9]. The mechanism is olfactory. Women can, without conscious awareness, detect MHC compatibility information in body odour.

The foundational research was published in 1995 by Claus Wedekind and colleagues at the University of Bern [9]. In what became known as the “sweaty T-shirt study,” women were asked to rate the attractiveness of T-shirts worn by men whose MHC profiles had been characterised. Women not using hormonal contraception consistently preferred the scent of men with dissimilar MHC profiles, men whose biological makeup complemented their own. Women on the pill showed the opposite pattern. Their preferences shifted toward MHC-similar men, the odour profile associated with family members rather than optimal reproductive partners.

This was not a single anomalous finding. S. Craig Roberts and colleagues replicated and extended the work in 2008, publishing in the Proceedings of the Royal Society B [10]. Oral contraceptive use disrupted the MHC-based odour preferences that guide mate selection in normally cycling women.

If the pill places a woman in a hormonal state resembling pregnancy, and if pregnancy normally shifts olfactory and social preferences toward kin (which is biologically coherent, since a pregnant woman benefits from the proximity of protective relatives rather than from seeking new mates), then a woman on the pill is navigating mate selection with a preference system calibrated for a physiological state she is not actually in.

In 2012, Roberts and colleagues published a study examining what happens downstream [11]. Women who had met their current partner while using oral contraception and subsequently discontinued reported decreased sexual satisfaction with and attraction to their partner, compared to women who had met their partner while not on the pill. The relationships of the “met on the pill” group were, however, less likely to have ended, a finding the authors attributed to shared investment, children, and social structures that maintain partnerships independent of sexual attraction.

A woman on the pill may select a partner she would not have chosen in her natural hormonal state. When she discontinues, often to start a family, her natural preferences reassert themselves. The attraction dims. But by then, the relationship has accrued commitments that make separation costly. A 2010 review in Trends in Ecology & Evolution by Alvergne and Lummaa synthesised this body of research and concluded that the contraceptive pill alters mate choice in humans [12]. If hormonal contraception shifts partner preferences at a population level, the authors noted, the effects on relationship stability, sexual satisfaction, and offspring health are significant and widespread. They called for further investigation. The prescribing documents for these drugs have not incorporated any of this research.

Hundreds of millions of women have formed partnerships, married, and built families while under the pharmacological influence of these drugs. The possibility that the drug altered their mate preferences, a possibility supported by published, replicated research in major journals, was not investigated by the companies that made these products, not flagged by the agencies that approved them, and not mentioned by the physicians who prescribed them.

The words “partner,” “attraction,” “mate selection,” “MHC,” and “relationship satisfaction” do not appear in any of the five labels. The most widely prescribed drug class in women’s reproductive health was approved and marketed for decades without any examination of whether it changes whom a woman is drawn to, or what happens to that attraction when the drug stops.

Five Pills, Same Architecture

The differences between these five pills are pharmacological variations on a single theme. All five deliver ethinyl estradiol at doses ranging from 0.02 mg (Yaz, Aviane) to 0.035 mg (Sprintec) [1–5]. The progestins differ in chemical structure and receptor-binding profile, but all serve the same purpose: constant progesterone-like signalling that suppresses ovulation.

Drospirenone, the progestin in Yaz, is unique among this group [1]. A spironolactone analogue with anti-mineralocorticoid and anti-androgenic properties, it can lower blood pressure slightly and reduce androgen-related effects like acne, which is what made Yaz one of the most commercially successful oral contraceptives in history. It also raises potassium levels, making Yaz contraindicated in women with kidney, liver, or adrenal disease and potentially dangerous with common medications including NSAIDs, ACE inhibitors, and potassium-sparing diuretics. The same properties that differentiate Yaz commercially give it the highest documented venous thromboembolism risk among these five pills.

Levonorgestrel, the progestin in Aviane, sits at the other end of the risk spectrum [5]. The oldest of the four progestins, with the most accumulated safety data. Its VTE risk is the lowest among combined oral contraceptives, which is why it typically serves as the comparator in thromboembolism studies. It also has mild androgenic activity, the opposite of drospirenone’s profile, which is why levonorgestrel pills are less commonly prescribed for acne.

Desogestrel, in Apri, is a third-generation progestin associated in some studies with higher VTE risk compared to levonorgestrel, though the data is less extensive than for drospirenone [3]. Norgestimate, in Sprintec, is also third-generation with low androgenic activity and a generally favourable risk profile [2]. Norethindrone acetate, in Junel Fe, is a first-generation progestin with moderate androgenic activity [4].

These distinctions matter at the margin. A woman with a family history of blood clots faces a different risk calculation with Yaz than with Aviane. A woman concerned about acne may respond differently to drospirenone than to levonorgestrel.

But the fundamental mechanism is identical across all five. All suppress ovulation, eliminate the natural menstrual cycle, and hold the endocrine system in a constant synthetic state. All increase the risk of blood clots, list depression among their side effects, acknowledge decreased libido, and admit in their prescribing documents that significant questions about long-term safety remain open. The differences between brands are variations in the synthetic progesterone molecule. The underlying intervention, the suppression of a woman’s natural hormonal rhythm and its replacement with a chemical steady state, is the same.

What the Documents Say

The five prescribing documents reviewed for this essay are public records [1–5]. They were written by Bayer (Yaz), Barr Laboratories (Sprintec), Teva Canada (Apri), multiple generic manufacturers (Junel Fe), and Teva Pharmaceuticals (Aviane). They were approved by the FDA and Health Canada. They are available to anyone who asks, or who unfolds the paper packed inside the box.

These documents acknowledge that oral contraceptives increase the risk of blood clots, stroke, and heart attack. They acknowledge associations with breast cancer, cervical cancer, and liver tumours. They list depression, mood changes, decreased sexual desire, and weight changes among their known side effects. They admit that the long-term effects of the specific formulations being sold today remain undetermined. They disclose that key pharmacological parameters were never specifically measured for some of these products. They reveal clinical trials of a thousand women lasting a year, upon which the safety case for decades of continuous use was built.

What they do not contain is any investigation into the effects of these drugs on a woman’s psychological development, cognitive function, partner selection, relationship satisfaction, or the experience of discontinuation after years of use. The people who made the drugs did not ask these questions. The people who approved them did not require it. The people who prescribe them do not raise it.

The package insert runs to dozens of pages. It says what it says. And what it doesn’t say, about what happens to a woman’s mind, her desires, and her choices across a decade or two of suppressed ovulation, amounts to a set of questions that were never asked about a drug that was never designed with those questions in mind, prescribed to women who were never told the questions existed.

Informed consent requires information. Not a box handed across a pharmacy counter, but an actual conversation about what a drug does, what it is known to cause, what has never been studied, and what a woman will experience in her body, her mind, and her relationships over the years she is expected to take it. That conversation has not been happening. The information needed for it has been available all along, printed in small type on thin paper, folded and tucked inside the packaging, since the day each prescription was filled.

The documents are there. They have always been there. They are folded up inside the box.

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References

[1] Bayer HealthCare Pharmaceuticals. Yaz (drospirenone and ethinyl estradiol) tablets prescribing information. FDA Reference ID: 5177006.

[2] Barr Laboratories. Sprintec (norgestimate and ethinyl estradiol) tablets prescribing information. Revised January 2011.

[3] Teva Canada Limited. Apri 21 and Apri 28 (desogestrel and ethinyl estradiol) tablets prescribing information. DIN 02352346 / 02352354.

[4] Junel Fe (norethindrone acetate and ethinyl estradiol tablets and ferrous fumarate tablets) prescribing information. ANDA076380. Revised January 2025.

[5] Teva Pharmaceuticals USA. Aviane (levonorgestrel and ethinyl estradiol) tablets prescribing information. Revised August 2024.

[6] Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of hormonal contraception with depression. JAMA Psychiatry. 2016;73(11):1154–1162.

[7] Skovlund CW, Mørch LS, Kessing LV, Lange T, Lidegaard Ø. Association of hormonal contraception with suicide attempts and suicides. American Journal of Psychiatry. 2018;175(4):336–342.

[8] Panzer C, Wise S, Fantini G, et al. Impact of oral contraceptives on sex hormone-binding globulin and androgen levels: a retrospective study in women with sexual dysfunction. Journal of Sexual Medicine. 2006;3(1):104–113.

[9] Wedekind C, Seebeck T, Bettens F, Paepke AJ. MHC-dependent mate preferences in humans. Proceedings of the Royal Society B. 1995;260(1359):245–249.

[10] Roberts SC, Gosling LM, Carter V, Petrie M. MHC-correlated odour preferences in humans and the use of oral contraceptives. Proceedings of the Royal Society B. 2008;275(1652):2715–2722.

[11] Roberts SC, Klapilová K, Little AC, et al. Relationship satisfaction and outcome in women who meet their partner while using oral contraception. Proceedings of the Royal Society B. 2012;279(1732):1430–1436.

[12] Alvergne A, Lummaa V. Does the contraceptive pill alter mate choice in humans? Trends in Ecology & Evolution. 2010;25(3):171–179.

[13] United Nations, Department of Economic and Social Affairs, Population Division. World Family Planning 2022: Meeting the changing needs for family planning. New York: United Nations, 2022. Reports 966 million contraceptive users worldwide as of 2021.

[14] Institut National d’Études Démographiques (INED). Contraception across the world (2022). Reports the pill at 16% of all contraceptive use (approximately 151 million users based on UN population data).

[15] GoodRx. America’s Most Prescribed Birth Control: Sprintec, Junel FE, and Apri. 2022. Identifies Sprintec, Junel FE, and Apri as the most commonly prescribed oral birth control options in the United States.

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