Warning: This is completely based on my own experiences; please do your own research before trying different types of birth control.

TL;DR: Sex hormone binding globulin (SHBG), which is anti-correlated with free testosterone, seems to predict how well I tolerate birth control. None of them does everything I want--I just want to be me without the painful periods smh.

I started getting painful cramps in high school, but it was mostly manageable as long as I took some Tylenol within eight hours of my period starting. If I forgot, I was mostly fine, just in some pain. I would cramp for a few hours, and then it would subside. By the time I finished college, if I didn't take Tylenol^[1] within that timeframe, I would be bent over in pain and nausea for a while, maybe half an hour, I don't remember anymore. It would drain me of all energy, and I'd be tired for another few hours. I almost always had irregular periods; I learned at the end of college that if I worked out 4 days a week, I could have a regular period that didn't hurt a ton.

Then grad school happened. The summer before was insanely stressful; and a few weeks into the semester it was bad enough that I had to skip seminars and take sick leave. I started lifting regularly again, until COVID knocked me out around Thanksgiving. At that point I decided to go on birth control to prevent periods from interfering with my life.

Choosing a Progestin

After doing some reading, I knew I needed an anti-androgenic progestin, which restricts to what's known as fourth-gen progestins. I had mild acne (closed comedones), and some unwanted hair growth. First- and second-gen progestins are pretty androgenic, and third-gen is mildly so. All combination birth control pills (estrogen + progestin) increase sex hormone binding globulin (SHBG) substantially, which binds to free testosterone. Anti-androgenic progestins raise SHBG more than their less-androgenic counterparts.

There are three fourth-gen progestins used in birth control in the US: drospirenone, dienogest, and segesterone acetate. Over the next three years, I would try all of them.

Annovera (Feb-April 2023)

I started with an online service that would just mail you your birth control. They prescribed me Annovera, which is a vaginal ring with 0.15 mg/day of segesterone acetate and 0.013 mg/day of ethinyl estradiol. You leave it in for 21 days. This seemed like a great idea to me, since I don't have to remember to take pills every day.

But after six weeks, it gave me really bad depression. I felt sad, I cried a lot, I didn't want to do anything, and had self-harm thoughts. The online service refused to change my birth control just because of self-harm ideation, and so I went to my school's health clinic.

Yasmin (April 2023-Feb 2025)

The nurse practitioner prescribed me Yasmin, which is 3 mg drospirenone and 0.03 mg ethinyl estradiol. Yaz is the same combination at a lower dose (2 mg drospirenone and 0.02 mg ethinyl estradiol) and is indicated for mood, but the lower estrogen dose carries a higher risk of side effects like reduced bone density. So she thought that I'd probably would do well on Yasmin. I felt better on this birth control compared to Annovera; I could do things again.

But the depression came back slowly. About a year in, my college roommate visited and straight-up asked if I was depressed. I thought that I wasn't; I did have very little motivation to do things, but I attributed it to a combination of being disillusioned with grad school and a lack of direction on what else to do. I thought that I was fine, and so I kept taking it.

But it eventually got too much--it was really hard for me to get out of bed, I didn't want to do anything, I felt very lethargic, etc. By this point, I had figured out what I want do after grad school, so grad school depression no longer explained the dullness. I would also feel better on the pill-free week, and so I dreaded taking it every morning. I started missing pills. I had to change birth control.

Nuvaring (March-May 2025)

Since fourth-gen progestins so far seem to make me lose motivation to do things, I decided to try a third-gen progestin, which is only mildly androgenic if at all. I was missing pills, so a ring would solve my dosing issues. The only other ring on the market is the Nuvaring (0.12 mg/day of etonogestrel and 0.015 mg/day of ethinyl estradiol).

I think I vaguely had a better ability to do things, but I'm not sure. But my skin started breaking out. I've had closed comedones on my face since I was a teen, and birth control (Annovera) cleared it up and it hasn't come back since then.

My periods also started cramping again, so I couldn't stay on this birth control, especially when the entire point is to minimize period disruption in my life.

Natazia (May 2025-Present)

I talked to o3 about all the different birth control pills that I'd tried, and it suggested Natazia (estradiol valerate and dienogest), the remaining 4th gen progestin that I hadn't tried. It's quadriphasic, so there are four different pills in a pack, with different dosing of estrogen/progestin. o3 said that the progestin and estrogen are both a bit milder, and doesn't raise SHBG (sex hormone-binding globulin) as much, so I should have more energy to do things.

Prescribers are more hesitant to prescribe it because all pills need to be taken at the ~same time every day, or within a 12-hour window. Missing one pill is complicated. On typical birth control, you just take both pills and move on with your life. Missing one pill on Natazia could mean that you would need to use backup birth control if you're sexually active for nine days, and maybe need to throw the entire remainder of the pack away, depending on how many pills in that pack you've already taken.

Natazia has been the best so far, but not without issues. After a year, I'm getting mild acne again, and my mood swings seem to correlate with the end of the pack, just like PMS. I also need to be on insurance; the drug out-of-pocket costs over $200/month. Generics don't exist because it's "new" (patent approved in 2011).

Nextstellis (March 2026)

I'd gotten Nextstellis (3 mg drospirenone and 14.2 mg estetrol) prescribed around the same time as Natazia. It has the same progestin as Yasmin (drospirenone), but a different estrogen that was supposed to be more biosimilar and thus create a lower rise in SHBG.

I tried it because I ran out of Natazia, and no pharmacy had it in stock--downsides of having a non-generic, new birth control I guess. Supposedly your clotting risk is the highest in the first year of being on birth control, and stopping resets the clock, so going unmedicated seemed bad. So I decided to take Nextstellis. Within a week of being on it, I was very teary and didn't want to do anything. I didn't finish the pack, and went back to Natazia.

Conclusion

Aella found that the effect size of birth control on mood is very small, and a large UK study concluded that birth control moderately increases your risk of depression in the first two years. But I think mood is very hard to track, you can get used to the new normal if it happens slow enough. I definitely cry more on birth control, but it's been so long that I don't completely remember what I was like before.

Most discussions of birth control side effects focus on acne, mood, and weight, but SHBG changes seem to drive the changes for me. It explains how I'd react to a new pill pretty well.

So I've tried all the 4th-gen progestins. I wish there were more.

1. ^{^}

   Some women really like ibuprofen but it never worked well for me.