Which Progestin Is Right for You?

What a progestin actually does

Every progestin suppresses ovulation and thickens cervical mucus — that part is shared across all of them, and it's what makes the pill work as contraception. What differs is how much each one also acts like testosterone (androgenic effects — more oil/acne, sometimes hair growth) versus blocking testosterone's effects (antiandrogenic — often better for acne and unwanted hair growth), plus smaller differences in mood effects, bloating, and clotting risk. That spectrum, androgenic to antiandrogenic, is the single most useful way to think about the differences below.

First and second generation: norethindrone and levonorgestrel

Norethindrone (1st generation) and levonorgestrel (2nd generation) are the oldest, most-studied progestins, and levonorgestrel in particular is the reference point most VTE (blood clot) risk studies compare everything else against — it carries the lowest added clotting risk among combined pills, which is why it's often a first-line recommendation, especially if cost or clotting risk are your priority. The tradeoff is that both are relatively androgenic, so acne or oily skin can be more noticeable on these than on a more antiandrogenic option.

Common brand names: levonorgestrel combined pills include Levora, Portia, Lutera, Aviane, Seasonique, and Ashlyna; norethindrone combined pills include Loestrin, Junel, and Microgestin. Norethindrone alone (no estrogen) is also the progestin in several progestin-only "mini-pills," like Camila and Errin.

Third generation: norgestimate and desogestrel

Norgestimate and desogestrel were developed specifically to be less androgenic than levonorgestrel — better for acne and hirsutism (excess hair growth) — which is part of why they're commonly chosen for patients with PMOS or androgen-related skin concerns. The tradeoff, seen consistently across large studies, is a modestly higher VTE risk than levonorgestrel pills, on the order of roughly 1.5–2x — still a low absolute risk for most healthy patients, but worth knowing and factoring into your own risk profile.

Common brand names: norgestimate combined pills include Ortho Tri-Cyclen, Sprintec, and TriNessa; desogestrel combined pills include Apri, Desogen, and Cyclessa.

Fourth generation: drospirenone (and dienogest)

Drospirenone is chemically related to spironolactone and is the most antiandrogenic progestin in common use — often the best option specifically for acne, and Yaz is FDA-approved specifically for PMDD (premenstrual dysphoric disorder), not just contraception. It also has a mild diuretic, potassium-sparing effect, which is why it's generally avoided with kidney, liver, or adrenal disease, or with medications that also raise potassium (like certain blood pressure medications) — your provider will ask about this. VTE risk with drospirenone appears somewhat higher than with levonorgestrel in most studies, similar to or slightly above the third-generation progestins.

Common brand names: Yaz, Yasmin, Ocella, Syeda, and Safyral (which also includes folate). Dienogest, a related antiandrogenic progestin, is paired with estradiol valerate in Natazia — notable because it's also separately used (without estrogen, at a higher dose) as a treatment for endometriosis pain, not just contraception.

What actually matters for you

Your own history changes this more than the general pattern above: migraine with aura, a personal or strong family history of blood clots, smoking (especially over 35), and obesity all raise clotting risk regardless of which progestin you choose, and may steer your provider toward a lower-VTE-risk option or away from combined pills entirely. If acne, hirsutism, or PMDD symptoms are your main concern, that's worth naming directly — it points toward the more antiandrogenic end of the spectrum. And if you've tried one pill and had side effects (mood changes, breakthrough bleeding, persistent acne), switching to a different progestin — not just giving up on the pill entirely — is a reasonable next step many people don't realize is an option.