Extended Hormonal Contraception

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  • There is no medical reason to bleed while on hormonal contraceptives.
  • Periods on the pill are actually withdrawal bleeding, which seems like a natural, regular cycle. Adding estrogen and then cycling it (withdrawing it) triggers regular withdrawal bleeding.
  • Menstrual blood does not build up when women are on hormonal methods.

Safety

  • According to the current research, extended (91-day) use of OCs has been shown to be as safe as comparable-dose 28-day cyclic pills. Continuous use of any OC beyond 91 days has not been approved by the US Food and Drug Administration.
  • The decision to skip periods on the pill should be discussed with a health care provider. No patient should start using an OC on an extended or continuous basis without being warned that she will be exposed, on an annual basis, to a higher level of estrogen.
  • Patients who choose to extend their OC regimens using 28-day packs should be warned that they will need to use a monophasic OC and that, depending on the length of the cycle they choose, they will need an additional four to six packs per year.

Advantages

  • Can help alleviate conditions such as painful periods, excessive bleeding, premenstrual syndrome, and menstrual-related migraine headaches.
  • With conventional OCs, more side effects, such as bloating, headaches, and breast tenderness, occur during the pill-free interval than during the active pill phase. Eliminating this pill-free interval may reduce these side effects.
  • More convenient in general and during particular occasions, such as vacations and athletic activities.
  • Don’t need to purchase and carry as many hygiene products (after six months).

Disadvantages

  • Can have unpredictable breakthrough bleeding as with conventional OCs. It will lessen as the body adjusts to new hormone balance.
  • Hygiene products still needed, particularly in the early cycles.
  • Sex partner may be bothered by frequent spotting in the early extended cycles or early months of continuous use.
  • Need to remember schedule, such as when to take pill or change patch.
  • May be more difficult to tell if pregnant. Look for other signs of pregnancy, such as breast tenderness, nausea, fatigue, etc. If necessary, pregnancy tests can be performed.
  • Unknown risk associated with additional estrogen exposure.
  • Cost depends on the cycle length chosen. A typical 28-day cycle requires 13 pill packets for the year. A continuous regimen requires 18 packets. With Seasonale, the 84 days of active pills come in one packet, so four packets are needed for the year. Because most insurance plans cover only 13 pill packs per year, creating an extended or a continuous regimen with typical 28-day packs will result in added cost of four to six pill packs per year.

How to use contraceptive method for extended regimen

  • When to have hormone-free days, if at all.
  • Schedule of method, such as taking OCs at the same time every day.

What to expect

  • Irregular bleeding, typically very light and painless if low-dose OCs is used.
  • Blood is dark brown (oxidized due to remaining in vagina longer) rather than red (blood noted with active bleeding), but can also be bright red during the first six months.
  • Blood may have a grainy texture.

When to call provider

  • For side effects such as sudden-onset severe headache, leg or abdominal pain, chest pain or other symptoms that may indicate heart attack, or stroke.
  • For side effects such as heavy bleeding, nausea, vomiting, bloating, mood changes, headaches.

Pregnancy’s signs and symptoms, other than a missed period

  • Breast tenderness.
  • Fatigue.
  • Nausea.
  • Frequent urination.

Frequently Asked Questions About Extended and Continuous Hormonal Contraception

  1. Is it safe to use extended or continuous hormonal contraception?Studies on the extended OC regimen demonstrated that side effects were comparable with the conventional 21/7 regimen. Extended-use OCs was also found to be safe with respect to the uterus (womb and its lining).

    Seasonale is the only product approved by the FDA for extended use.

    For continuous use, hormone dose should be considered to reduce total hormone exposure. Low-dose (20 mcg EE) pills have been demonstrated effective in continuous regimens.

    Taking the pill continuously is not any riskier than taking monthly birth control pills, which are safe for most women. However, it is not yet known if skipping the pill-free week (getting nine extra weeks of hormones with Seasonale, 13 extra weeks with continuous regimen) might not increase or change some side effects.

    Today’s low-dose OCs contains much less estrogen than they did years ago. They now cause fewer side effects, such as nausea and fluid retention. They also remain very effective in preventing pregnancy.

    Some women should not take the pill, for example those with liver disease, severe high blood pressure, previous problems with blood clots in the legs or lungs, and women older than 35 years who smoke.

  2. Is it safe not to have a period every month?Health care providers have stopped women’s periods-through the continuous use of contraceptives-to treat a condition called endometriosis for years. No significant problems with this have been reported.
  3. What happens to the blood when I don’t have a period?In women who are not using hormones, every month female hormones signal the uterus to build up its lining and blood supply to make a healthy, nurturing place for a fertilized egg to grow. If the egg does not join with a sperm to start a pregnancy, the lining is no longer needed, so you have a period. The blood that comes out is the built-up lining of the uterus.

    Birth control pills and other contraceptives contain hormones that stop the egg from being released from the ovary and stop the lining of the uterus from building up. This leaves little or nothing to be released from the uterus. Taking OCs keeps the normal uterine lining from breaking down and bleeding. The lining remains thin and does not need to be flushed out each month.

  4. What should I do if I have spotting?Spotting is from some of the thinned-out uterine lining breaking down. It is not a period. Spotting is normal and common at first, as your body adjusts to the steady hormone levels. Eventually spotting stops.

    Spotting can happen on and off for around six months, sometimes for a little longer.

    The important thing is to take the pill or other contraceptive as suggested by your health care provider. With the pill, it is important to take it as close as possible to the same time every day. If the spotting continues beyond a few months, seems heavy, is overly bothersome, or you have any other concerns; call your health care provider.

  5. How often do I need to get a period?Women who take hormonal contraceptives do not need to have a period.

    In fact, women who breastfeed and do not supplement feedings usually do not get a period. They do not ovulate, so the lining of the uterus does not thicken.

    In some cultures, women breastfeed for two or three years continuously. During this time, they do not get a period. This is perfectly normal.

  6. How will I know if I’m pregnant?Pregnancies are rare in women who take OCs correctly. If you think you may be pregnant, you should have a pregnancy test. Use either a home pregnancy test that you can buy at the drug store or call your health care provider. Most home pregnancy tests can tell you if you are pregnant after about 10 days of pregnancy. Symptoms such as breast tenderness, feeling overly tired, and nausea can happen early in pregnancy-often before the first period is missed.

***Source: Association of Reproductive Health Professional (ARHP) Clinical Proceedings. Choosing when to menstruate: the role of extended contraception. Electronic edition, April 2003. (http://www.arhp.org/healthcareproviders/cme/onlinecme/extendedregimencp)

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